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. Avoiding fresh flowers in the room is unnecessary for a child with Clostridium difficile. Fresh flowers are typically restricted for clients who are immunocompromised, such as those undergoing chemotherapy or organ transplants, rather than those with infectious diarrhea.
B. Using an N95 respirator is incorrect. Clostridium difficile is transmitted via the fecal-oral route and requires contact precautions, not airborne precautions. An N95 mask is only required for airborne pathogens like tuberculosis or measles.
C. Initiating contact precautions is correct. Clostridium difficile is highly contagious and spreads through spores that can survive on surfaces. Contact precautions, including the use of gloves and gowns and proper hand hygiene with soap and water, help prevent transmission.
D. Placing the child in a room with a HEPA filtration system is unnecessary. HEPA filtration is used for airborne pathogens, whereas Clostridium difficile is spread via direct and indirect contact rather than through the air.
Correct Answer is B
Explanation
A. Carrying the baby to the nursery is incorrect. Most facilities require that newborns be transported in a bassinet, not carried, to reduce the risk of accidental drops or abductions.
B. Having an identification band that matches the baby’s band is correct. Hospital security protocols require that the mother and baby wear matching identification bands to ensure the right baby is with the right parent and prevent infant abduction or misidentification.
C. Removing the security band to give to a family member is incorrect. The security band must remain on the mother at all times to verify identity when interacting with the baby. Removing it can compromise security.
D. Taking the baby to the lobby to visit family is incorrect. Many hospitals have strict policies requiring newborns to remain in designated areas for security and infection control reasons. Visitors should come to the mother’s room instead.
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