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.)
Tachycardia.
Constipation.
Hyperthermia.
Vomiting.
Hypotension.
Correct Answer : A,C,D
The correct answers are choices A, C, and D: Tachycardia, Hyperthermia, and Vomiting.
Choice A rationale:
Tachycardia. Tachycardia, an abnormally fast heart rate, is a classic manifestation of thyroid storm. In this life-threatening condition, there is an excessive release of thyroid hormones, leading to increased metabolic rate and subsequent cardiovascular effects such as tachycardia.
Choice B rationale:
Constipation. This choice is incorrect for thyroid storm. Hyperthyroidism typically leads to increased bowel motility and can cause diarrhea rather than constipation.
Choice C rationale:
Hyperthermia. This is a correct choice. Thyroid storm is associated with severe hyperthermia due to the increased metabolic rate caused by excessive thyroid hormones. The body's temperature regulation is disrupted, leading to dangerously high body temperatures.
Choice D rationale:
Vomiting. This is a correct choice. Gastrointestinal symptoms, including vomiting and nausea, can occur in thyroid storm due to the heightened metabolic state. Thyroid storm affects various systems, including the gastrointestinal system, leading to symptoms like vomiting.
Choice E rationale:
Hypotension. This choice is incorrect for thyroid storm. Thyroid storm is more likely to cause hypertension rather than hypotension due to the increased cardiac output and sympathetic stimulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Explain in simple terms how it works.
Choice A rationale:
Asking the girl why she wants to know might be appropriate in some contexts, but children are naturally curious and seeking information is a common behavior. Explaining how the blood pressure apparatus works would likely be more beneficial than questioning her motivation.
Choice B rationale:
Determining why she is anxious assumes that the girl is anxious, which might not be the case. Additionally, the question she asked does not necessarily indicate anxiety, but rather a curiosity about the medical equipment.
Choice C rationale:
Explaining in simple terms how the blood pressure apparatus works is the most appropriate nursing action. This approach respects the child's curiosity and provides her with age-appropriate information, fostering a positive and educational interaction.
Choice D rationale:
Telling her that she will see how it works as it is used might not fully satisfy her curiosity or address her immediate question. Children often benefit from clear and concise explanations, especially when it comes to medical equipment.
Correct Answer is A
Explanation
The correct answer is choice A: Signs of stress.
Choice A rationale:
Children often express stress through physical complaints such as stomach pains, headaches, and fatigue. The 9-year-old's complaints of stomach pains, along with the description of aggressive and stubborn behavior, are indicative of stress. Stressors can include academic pressures, family issues, social challenges, or other emotional factors.
Choice B rationale:
Developmental delay refers to a situation where a child's developmental milestones are significantly delayed compared to their peers. This doesn't align with the presented symptoms of stomach pains, aggression, and stubbornness. These symptoms are more indicative of emotional or psychological distress.
Choice C rationale:
While a physical problem could potentially cause emotional stress, the scenario doesn't provide enough information to directly conclude that a physical problem is the primary trigger. Stomach pains could indeed result from emotional stress, and it's important to consider the child's overall well-being.
Choice D rationale:
Lack of adjustment to the school environment can lead to behavioral and emotional challenges, but it's not the most direct explanation for the symptoms described in the scenario. The combination of stomach pains and behavioral changes suggests a more immediate emotional trigger, which is often stress-related.
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