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 D
Explanation
A. "Once my health care proxy is in place, I relinquish my right to make my own decisions" is incorrect. A health care proxy only comes into effect when the individual becomes incapacitated and unable to make decisions. Until then, the client retains the right to make their own decisions.
B. "My health care proxy designee is not able to sign a consent form on my behalf" is incorrect. The health care proxy designee is authorized to make decisions about medical treatment, which includes signing consent forms on the client’s behalf if the client is unable to do so.
C. "If I have a health care proxy, then I do not need to have a living will" is incorrect. A living will and a health care proxy are separate documents. A living will specify a person’s wishes regarding medical treatments in case they are unable to communicate, while a health care proxy designates someone to make decisions on their behalf. Both can be used together.
D. "I do not need to name a relative as my designee in my health care proxy" is correct. The designee does not have to be a relative. The client can choose anyone they trust to make healthcare decisions on their behalf when they are unable to do so.
Correct Answer is A
Explanation
A. Wipe any excess medication from the inner canthus outward: This is the correct approach. When administering ophthalmic ointment, the nurse should wipe away any excess from the inner canthus to the outer canthus to prevent contamination of the unaffected eye and to avoid spreading the infection.
B. Instruct guardian to apply erythromycin ophthalmic ointment every morning for 14 days.: This is incorrect because the child has been prescribed bacitracin ophthalmic ointment, not erythromycin. The nurse should instruct the guardian to use the prescribed medication as directed.
C. Gently massage the eyelid to facilitate absorption of the medication.: Massaging the eyelid is unnecessary and could lead to irritation or injury. The medication should be allowed to be absorbed naturally without additional manipulation.
D. Place an occlusive dressing on the affected eye to prevent the spread of infection.: An occlusive dressing is not recommended as it may cause increased irritation or pressure on the eye. The best practice is to maintain proper hygiene and follow the prescribed medication regimen.
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