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. Having the client point his toes before inserting his foot into the stocking is incorrect. The nurse should instruct the client to keep the foot in a neutral position to avoid unnecessary pressure on the toes or veins.
B. Removing the stockings once every 24 hr is incorrect. Antiembolic stockings should typically be removed and reapplied at least once per shift to allow for skin assessment and hygiene. They should not remain on for 24 hours continuously.
C. Elevating the client's legs for 5 min prior to applying the stockings is correct. Elevating the legs helps promote venous return by reducing swelling in the lower extremities. This makes the application of antiembolic stockings more effective and more comfortable for the client.
D. Rolling the top of the stocking down so it fits snugly above the client's calf is incorrect. The stockings should be applied smoothly and without folds to avoid restricting circulation. The top should not be rolled down as it can create pressure points
Correct Answer is C
Explanation
A. Encouraging the client to write about her feelings in a journal each day.: While journaling can be therapeutic, it may not be the best immediate intervention. The client may first need support and validation of her feelings before engaging in such an activity.
B. Demonstrating a nonjudgmental attitude toward the client when providing care for her surgical wounds.: This is important for maintaining therapeutic communication, but it does not address the emotional distress the client is currently experiencing.
C. Identifying the client's perception of the changes in her physical appearance.: The client is likely struggling with body image changes following a bilateral mastectomy. The priority should be to assess the client’s emotional response to her altered appearance and to offer emotional support. This provides the foundation for helping the client process her feelings.
D. Providing the client with information on community resources that will strengthen her coping skills.: While community resources can be helpful later on, the immediate priority is understanding the client’s emotional response to her surgery. Once the nurse has established the client's emotional needs, then providing resources may be more appropriate.
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