A nurse is planning care for a client who is experiencing thyroid storm triggered by a systemic infection. Which of the following interventions should the nurse plan to take?
Request a prescription for levothyroxine IV.
Administer supplemental oxygen to the client.
Cover the client with warm blankets.
Implement measures to increase the client's pulse rate.
None
None
The Correct Answer is B
Rationale:
A. Levothyroxine is used to treat hypothyroidism, not hyperthyroidism. In a Thyroid storm, thyroid hormone levels are already dangerously elevated. Giving levothyroxine would worsen the condition and increase metabolic demand further.
B. Thyroid storm causes a severe hypermetabolic state, increasing oxygen consumption and demand. Supplemental oxygen helps; prevent hypoxia, support tissues under metabolic stress, reduce risk of organ failure. Therefore making it an important supportive, priority intervention.
C. Clients in thyroid storm typically have high fever (hyperthermia). The appropriate intervention is cooling measures (cooling blankets, antipyretics), not warming. Warm blankets would worsen hyperthermia.
D. Thyroid storm causes tachycardia (very fast heart rate) and risk of arrhythmias. Increasing the pulse rate would increase risk of complications such as heart failure. Therefore the goal is to decrease heart rate (e.g., beta-blockers) and reduce cardiac workload
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Reports intolerance to heat: Intolerance to heat is more commonly associated with conditions like hyperthyroidism rather than iron-deficiency anemia. Individuals with iron-deficiency anemia often experience fatigue and cold intolerance due to decreased oxygen-carrying capacity of the blood.
B) Develops bradycardia after eating: Bradycardia (slow heart rate) is not typically associated with iron-deficiency anemia. Anemia usually causes an increased heart rate (tachycardia) as the body tries to compensate for reduced oxygen delivery.
C) Has a friction rub on auscultation: A friction rub is a sound heard on auscultation associated with pericarditis, an inflammation of the pericardium, and is not a typical finding in iron-deficiency anemia. Anemia primarily affects the blood and does not usually cause inflammation of the heart lining.
D) Displays dyspnea while walking: Dyspnea, or shortness of breath, is a common symptom of iron-deficiency anemia, particularly with exertion. This occurs because the reduced hemoglobin levels result in decreased oxygen delivery to tissues, making physical activities more challenging and causing breathlessness.
Correct Answer is D
Explanation
A) Decrease folic acid intake: Decreasing folic acid intake is not advisable for clients with malabsorption syndrome. In fact, clients with malabsorption often require increased folic acid due to poor absorption of nutrients, especially in conditions like celiac disease or other causes of malabsorption.
B) Increase lactose intake: Increasing lactose intake is not appropriate for clients with malabsorption syndrome, particularly if they have lactose intolerance. Lactose can exacerbate symptoms such as diarrhea and steatorrhea in these clients.
C) Provide a gluten-free diet: A gluten-free diet is crucial for clients with celiac disease, which is a type of malabsorption syndrome. However, if the malabsorption syndrome is due to another cause, a gluten-free diet might not address the issue. The focus should be on managing fat intake to reduce steatorrhea.
D) Provide a low-fat diet: A low-fat diet is the most appropriate intervention for managing severe steatorrhea, which is the presence of excess fat in the stool. Reducing fat intake helps to minimize fat malabsorption and the associated symptoms, providing relief from steatorrhea.
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