A nurse is teaching a client who has Graves' disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse include in the teaching?
Increased temperature
Lethargy
Decreased heart rate
Hypotension
The Correct Answer is A
A Hyperthermia is a hallmark sign of thyroid storm due to the body's increased metabolic rate and inability to dissipate heat efficiently. High fever is a critical sign that should prompt immediate medical evaluation and treatment.
B. While fatigue and lethargy can occur in hyperthyroidism, they are not prominent features of thyroid storm. Individuals with thyroid storm typically exhibit agitation, restlessness, or even delirium due to the effects of excessive thyroid hormone on the central nervous system.
C. Bradycardia is not a feature of thyroid storm. Instead, individuals typically experience severe tachycardia, which can lead to palpitations, chest pain, and cardiovascular complications.
D. Thyroid storm is more commonly associated with hypertension rather than hypotension. Increased cardiac output and vascular resistance contribute to elevated blood pressure during thyroid storm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Respiratory infections can spread via droplets, necessitating airborne precautions and isolation in a private negative pressure room to prevent transmission to other clients and healthcare workers.
A A compound fracture involves an open wound where the bone has punctured the skin. While this client may require isolation precautions due to the open wound, the primary concern is not infectious in nature.
C. Aspiration pneumonia can be caused by inhalation of oral or gastric contents into the lungs, leading to infection. Therefore, such a client does not require isolation.
D Acute ketoacidosis in diabetes mellitus is a metabolic emergency but is not typically contagious or requiring isolation precautions for infection control.
Correct Answer is D
Explanation
D. Wearing goggles or eye protection when irrigating a wound helps prevent splashes or sprays of contaminated fluid from entering the nurse's eyes.
A Gowns are typically used during direct patient contact if there is an expectation of substantial contact with blood or body fluids.
B Sterile gloves are not typically required for administering an intramuscular (IM) injection. Instead, clean non-sterile gloves are sufficient to maintain aseptic technique during the procedure.
C. Recapping needles using both hands can increase the risk of needlestick injuries. It is recommended to use a one-handed scoop method or a safety device to recap needles safely.
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