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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Check the client's vital signs every 4 hr.: Although monitoring vital signs is important, it is not the primary concern in acute mania unless the client is showing signs of physical distress (e.g., tachycardia, dehydration).

B. Provide the client with high-calorie finger foods.: This is correct. During acute mania, clients may have difficulty sitting down to eat, and high-calorie finger foods can help ensure the client gets adequate nutrition. These foods are easy to consume and provide the necessary calories.

C. Encourage the client to participate in group activities.: While socialization can be beneficial, group activities may overstimulate a client in acute mania and could lead to further agitation. It is better to encourage more structured and individual activities initially.

D. Allow the client to establish his own schedule.: Clients in acute mania may have poor judgment and impulsive behavior. Allowing them to establish their own schedule could lead to disorganized behavior. The nurse should offer structure to prevent this.

A. Contact the provider within 48 hr to obtain a prescription for the restraints. B. Remove the restraints from the client's wrists every 2 hr. C. Check that one finger will fit between the client's wrists and the restraints. D. Fasten the restraints' ties to the bed's side rails.

Correct Answer is B

Explanation

A. Contacting the provider within 48 hr is incorrect. A prescription for restraints must be obtained within 1 hour of applying restraints, not within 48 hours. The nurse should ensure that this prescription is obtained promptly.

B. Removing the restraints every 2 hr is correct. The nurse should remove the restraints every 2 hours to assess the skin, provide range-of-motion exercises, and offer comfort. This ensures that the client is not harmed from prolonged restraint use.

C. Checking that one finger fits between the client's wrists and the restraints is incorrect. The nurse should ensure that the restraints are snug but not too tight to cause injury, typically allowing for two fingers of space, not just one.

D. Fastening the restraints' ties to the bed's side rails is incorrect. Restraints should be fastened to a movable part of the bed frame (not side rails) to prevent injury or accidental strangulation. The side rails can move and cause undue tension on the restraints.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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