A nurse is caring for a client who has Graves' disease. Which of the following findings should indicate to the nurse that the client is developing a thyroid storm?
Tachycardia
Hypotension
Neck pain
Respiratory depression
The Correct Answer is A
A. Tachycardia: This is correct. Tachycardia is one of the hallmark signs of thyroid storm, a life-threatening complication of hyperthyroidism (often seen in Graves' disease.. The excessive thyroid hormone leads to severe metabolic disturbances, including an increased heart rate.
B. Hypotension: Hypotension is not typically a feature of thyroid storm. In fact, thyroid storm is more commonly associated with hypertension due to the increased heart rate and metabolic activity.
C. Neck pain: Neck pain is not a common symptom of thyroid storm. Neck pain might be related to other conditions, such as thyroiditis or a goiter, but not specifically thyroid storm.
D. Respiratory depression: Respiratory depression is not a typical symptom of thyroid storm. On the contrary, thyroid storm often leads to symptoms like hyperventilation, not depressed breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Using patterned-paced breathing is typically associated with labor pain management rather than postoperative pain following a cesarean birth. While controlled breathing can help with discomfort, it is not the most effective strategy for incision-related pain.
B. Changing positions as little as possible is incorrect. Early mobility is encouraged after a cesarean birth to promote circulation, prevent complications like deep vein thrombosis, and aid recovery. Avoiding movement can lead to stiffness and prolonged discomfort.
C. Splinting the incision with a pillow is correct. Holding a pillow firmly against the incision while changing positions provides support, reduces strain on the abdominal muscles, and minimizes pain during movement.
D. Applying counterpressure to the back is incorrect. Counterpressure is a technique used for back labor pain during childbirth and is not relevant for post-cesarean incision pain.
Correct Answer is A
Explanation
A. There is one finger width between the strap on the mask and the client's face is correct. A properly fitted CPAP mask should have a snug fit, with a space of about one finger width between the strap and the face to ensure adequate seal and comfort. A mask that is too tight can cause discomfort, while a loose mask may not provide the necessary pressure to treat sleep apnea.
B. The therapeutic dose of albuterol is being inhaled is incorrect. Albuterol is used for bronchodilation in conditions like asthma, but it is not related to CPAP use. CPAP is designed to provide positive pressure to keep the airways open, not to treat asthma or other respiratory issues directly.
C. The mask fits loosely so air can escape from underneath is incorrect. A loose fit would lead to air leakage, reducing the effectiveness of the CPAP therapy. The mask should fit securely to ensure the proper amount of air pressure is delivered during sleep.
D. The mask is secured over the client's mouth and the client's nose is uncovered is incorrect. For effective CPAP therapy, the mask should cover both the nose and mouth, unless the client specifically uses a nasal CPAP mask designed to deliver pressure only through the nose.
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