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 C

Explanation

A. Elevated blood pressure: Diabetic ketoacidosis (DKA. typically does not cause elevated blood pressure. In fact, due to dehydration from increased urination, clients often present with hypotension or normal blood pressure, rather than hypertension.

B. Bounding pulse: A bounding pulse is not commonly associated with DKA. It may be seen with conditions such as fever or sepsis, but DKA is more likely to cause a weak or thready pulse due to fluid volume deficit and dehydration.

C. Fruity breath odor: A fruity or acetone-like breath odor is a hallmark sign of diabetic ketoacidosis. This is caused by the presence of ketones in the blood, which are produced as the body breaks down fat for energy when glucose is unavailable.

D. Clammy skin: Clammy skin is more likely to be associated with hypoglycemia, not DKA. In DKA, the skin is typically dry due to dehydration, and the client may appear flushed, not clammy.

A. "You should use patterned-paced breathing when changing positions." B. "You should change positions as little as possible." C. “You can splint the incision with a pillow when changing positions.” D. "You can apply counterpressure to your back with each position change."

Correct Answer is C

Explanation

A. Using patterned-paced breathing is typically associated with labor pain management rather than postoperative pain following a cesarean birth. While controlled breathing can help with discomfort, it is not the most effective strategy for incision-related pain.

B. Changing positions as little as possible is incorrect. Early mobility is encouraged after a cesarean birth to promote circulation, prevent complications like deep vein thrombosis, and aid recovery. Avoiding movement can lead to stiffness and prolonged discomfort.

C. Splinting the incision with a pillow is correct. Holding a pillow firmly against the incision while changing positions provides support, reduces strain on the abdominal muscles, and minimizes pain during movement.

D. Applying counterpressure to the back is incorrect. Counterpressure is a technique used for back labor pain during childbirth and is not relevant for post-cesarean incision pain.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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