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 A
Explanation
A. Headaches with aura is correct. Headaches with aura, a warning sign that can precede a migraine, are a contraindication for the use of oral contraceptives. This is because oral contraceptives increase the risk of stroke, especially in women who experience migraines with aura.
B. History of mononucleosis 1 year ago is incorrect. There is no specific contraindication for oral contraceptives related to a history of mononucleosis. This condition does not affect the effectiveness or safety of oral contraceptive use.
C. Irregular menstrual cycles is incorrect. Irregular menstrual cycles are not a contraindication for oral contraceptive use. In fact, oral contraceptives may help regulate menstrual cycles.
D. Gastroesophageal reflux disease (GERD. is incorrect. While GERD may cause discomfort, it is not a contraindication for oral contraceptives. Women with GERD can typically use oral contraceptives safely.
Correct Answer is D
Explanation
A. Administering a subcutaneous insulin injection requires nursing knowledge and skill to ensure correct dosage, technique, and monitoring for side effects. This should not be delegated to an assistive personnel (AP).
B. Removing an NG tube requires nursing assessment to determine if removal is appropriate and safe for the client. It also requires skill in managing complications that may arise. This should not be delegated to an AP.
C. Providing discharge teaching about home IV medication therapy is a complex task that requires nursing knowledge about medication management, potential complications, and instructions for safe administration. It cannot be delegated to an AP.
D. Collecting a sputum culture can be delegated to an AP. This is a task within their scope of practice, provided the AP has been trained in collecting samples and the procedure is straightforward.
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