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 A
Explanation
A) Stroke:
Hyperlipidemia and type 2 diabetes mellitus both contribute significantly to the development of atherosclerosis, which can lead to stroke. High levels of lipids in the blood can cause plaque buildup in the arteries, and diabetes can damage blood vessels and increase the likelihood of clots forming.
B) Benign prostatic hyperplasia:
While benign prostatic hyperplasia is a common condition in older men, it is not directly related to hyperlipidemia or diabetes. It is more related to age and hormonal changes rather than metabolic or vascular conditions.
C) Meniere’s disease:
Meniere's disease is a disorder of the inner ear that leads to vertigo, tinnitus, and hearing loss. It is not associated with hyperlipidemia or diabetes. The primary risk factors are genetic predisposition and abnormalities in the ear's fluid dynamics.
D) Hemophilia:
Hemophilia is a genetic disorder that affects the blood's ability to clot. It is inherited and not influenced by lifestyle-related conditions such as hyperlipidemia or diabetes. The risk factors for hemophilia are primarily genetic, with no direct link to metabolic conditions.
Correct Answer is D
Explanation
A) Dyspepsia:
Dyspepsia, or indigestion, is a common symptom of peptic ulcer disease, causing discomfort in the upper abdomen. While it is uncomfortable and should be managed, it is not immediately life-threatening and does not require urgent intervention compared to other symptoms.
B) Nausea:
Nausea can be a distressing symptom associated with peptic ulcer disease, often resulting from irritation of the stomach lining. Although it can significantly impact the client’s well-being and appetite, it is not as critical as symptoms indicating active bleeding or more severe complications.
C) Hyperactive bowel sounds:
Hyperactive bowel sounds may be present in peptic ulcer disease due to increased gastrointestinal activity. This finding suggests heightened digestive activity but does not indicate an immediate life-threatening condition that would take precedence over signs of active bleeding.
D) Hematemesis:
Hematemesis, or vomiting blood, is a serious and potentially life-threatening symptom that indicates active gastrointestinal bleeding. This requires immediate medical attention to prevent significant blood loss, shock, and other complications. It is the priority finding because it poses the most immediate risk to the client’s health and stability.
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