The nurse auscultates a systolic murmur in the second intercostal space to the right of the sternum while performing a cardiac assessment on a client. The nurse interprets this finding as:

hoice A reason: Preparing for endotracheal intubation and ventilatory support is not the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with respiratory failure or impending airway obstruction, which are not the case for this client.

Choice B reason: Providing continuous sedation for pain relief is not the action that the nurse should take for a client with thyroid storm. This intervention may worsen the client's condition by suppressing the respiratory drive and lowering the blood pressure. The nurse should administer antithyroid medications, beta blockers, and corticosteroids as prescribed to reduce the thyroid hormone levels and the associated symptoms.

Choice C reason: Initiating cardiac monitoring and assessing for reflex bradycardia is not the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with hyperkalemia or digoxin toxicity, which are not the case for this client. The nurse should monitor the client's heart rate and rhythm, but not expect a reflex bradycardia, which is a paradoxical slowing of the heart rate in response to a rapid rise in blood pressure.

Choice D reason: Maintaining IV fluid infusion and assessing adequacy of hydration is the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with thyroid storm, as they are at risk of dehydration and electrolyte imbalance due to increased metabolic rate, fever, sweating, vomiting, and diarrhea. The nurse should administer isotonic fluids, such as normal saline, and monitor the client's fluid intake and output, urine specific gravity, and serum electrolytes.

Choice A reason: Avoiding strenuous activity and standing up slowly is not a relevant response to the client's complaint of headache. These actions may help prevent or reduce orthostatic hypotension, which is another possible side effect of nitroglycerin, but not headache.

Choice B reason: Headache is expected and should subside with continued use is a correct and appropriate response to the client's complaint of headache. The nurse should explain that headache is a common and transient side effect of nitroglycerin, which is caused by the vasodilation effect of the drug. The nurse should also advise the client to take over-the-counter analgesics, such as acetaminophen, to relieve the headache.

Choice C reason: Reducing the dosage to help relieve this side effect is not a correct or appropriate response to the client's complaint of headache. The nurse should not suggest any changes in the prescribed dosage of nitroglycerin, as this may compromise the effectiveness of the drug and increase the risk of angina or myocardial infarction. The nurse should also remind the client to follow the instructions for applying and removing the Nitropatch.

Choice D reason: You will have this side effect as long as you are taking nitroglycerin is not a correct or appropriate response to the client's complaint of headache. The nurse should not discourage or alarm the client by implying that the headache is inevitable and permanent. The nurse should reassure the client that the headache will likely diminish over time as the body adapts to the drug.