The nurse is caring for a school-age child with hyperthyroidism (Graves’ disease). Which clinical manifestations should the nurse monitor that may indicate a thyroid storm? (Select all that apply)

 

Choice A reason:

Performing an ultrasound to determine if there is urinary retention is not the immediate priority action. While an ultrasound can help assess urinary retention, the presence of edema, redness, and the foreskin being behind the glans penis suggests a condition known as paraphimosis. Paraphimosis is a medical emergency that requires prompt attention to prevent complications such as tissue damage. Therefore, alerting the ER physician is the priority action.

Choice B reason:

Asking the parents specifically how long the infant has not voided is important for gathering information, but it is not the immediate priority action. The clinical signs of edema, redness, and the foreskin being behind the glans penis indicate a potential emergency that requires immediate medical intervention. While obtaining a detailed history is important, the nurse should first alert the ER physician to ensure timely management.

Choice C reason:

Alerting the ER physician to the patient’s condition is the correct priority action. The presence of edema, redness, and the foreskin being behind the glans penis suggests paraphimosis, which is a urological emergency. Prompt intervention is necessary to reduce the foreskin and restore normal blood flow to prevent tissue damage3. The ER physician can provide the necessary treatment and management for this condition.

Choice D reason:

Continuing to monitor the patient in the ER setting is not appropriate without first addressing the potential emergency. The signs of edema, redness, and the foreskin being behind the glans penis indicate a condition that requires immediate medical attention. Monitoring alone is insufficient; the nurse must alert the ER physician to ensure prompt intervention.

The correct answer is

A. Unable to roll over back to front

B. Head lag

C. Feeding difficulties

D. Floppy posture

E. Arms are stiff

F. Does not smile

G. Unable to sit without support

H. Irritable and cries often

I. Unable to pass an object between hands

Choice A reason

Unable to roll over back to front: At 3 months, infants typically start to develop the ability to roll over from their stomach to their back. Rolling over from back to front usually occurs later, around 4 to 6 months. However, the inability to roll over at all by 3 months could indicate developmental delays or muscle weakness, which requires follow-up.

Choice B Reason

Head lag: By 3 months, infants should have enough neck muscle strength to hold their head up when pulled to a sitting position. Persistent head lag at this age can be a sign of developmental delay or neuromuscular disorders, necessitating further evaluation.

Choice C Reason

Feeding difficulties: Infants should be able to suck and swallow effectively by 3 months. Feeding difficulties can lead to inadequate nutrition and growth, and may indicate underlying issues such as gastrointestinal problems or neurological disorders. This requires prompt attention and intervention.

Choice D Reason

Floppy posture: A 3-month-old should start to show more control over their body movements and have a more stable posture. Floppy posture, also known as hypotonia, can be a sign of various conditions, including genetic disorders, muscle diseases, or central nervous system issues. It is important to investigate the cause of hypotonia.

Choice E Reason

Arms are stiff: Stiffness in the arms, or hypertonia, can indicate neurological problems such as cerebral palsy or other motor disorders. It is crucial to assess the underlying cause of increased muscle tone and provide appropriate interventions.

Choice F Reason

Does not smile: Social smiling typically begins around 6 to 8 weeks of age. If a 3-month-old does not smile, it could be a sign of developmental delay, visual impairment, or other social and emotional issues. This warrants further assessment to determine the cause.

Choice G Reason

Unable to sit without support: While sitting without support is not expected until around 6 months, the inability to show any signs of trying to sit or maintain a sitting position with support at 3 months could indicate developmental delays. This should be monitored and addressed if necessary.

Choice H Reason

Irritable and cries often: Excessive irritability and frequent crying can be signs of discomfort, pain, or underlying medical conditions such as infections, gastrointestinal issues, or neurological problems. It is important to identify and address the cause of the infant’s distress.

Choice I Reason

Unable to pass an object between hands: By 3 months, infants should start to develop hand-eye coordination and the ability to grasp objects. The inability to pass an object between hands may indicate developmental delays or motor skill issues, which require further evaluation.