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.)

The correct answer is choice C. Dyspnea.

Choice A rationale:

Orthopnea. Orthopnea refers to difficulty in breathing that occurs when lying flat. It is not the term used to describe labored breathing, which is the main concern in this question.

Choice B rationale:

Hypopnea. Hypopnea is a term used to describe shallow or slow breathing, usually during sleep. It is not the term used to describe the labored breathing mentioned in the question.

Choice C rationale:

Dyspnea. This is the correct term to describe labored breathing, which is characterized by a subjective sensation of discomfort or difficulty in breathing. In this context, the nurse is charting that the hospitalized child has labored breathing, indicating the need for further assessment and intervention to address this breathing difficulty.

Choice D rationale:

Tachypnea. Tachypnea refers to abnormally fast breathing. While it is a concern, especially in the context of a hospitalized child, it does not specifically describe labored breathing, which is the main focus of this question.

The correct answer is choice D. Birth history.

Choice A rationale:

The heading "Chief complaint" is used to document the primary reason for the patient seeking medical attention, such as their main symptom or concern. This is usually stated in the patient's own words and provides context for the visit, but it does not encompass information about the circumstances of birth or prematurity.

Choice B rationale:

"Review of systems" involves a systematic approach to inquire about the patient's current symptoms or physical complaints across different body systems. It helps to identify any additional issues the patient might not have mentioned initially, but it does not pertain to birth history or prematurity.

Choice C rationale:

"Present illness" is the section where the nurse documents the patient's current health concern, including the details of the symptoms, their onset, duration, and any associated factors. However, it does not encompass information about the circumstances of birth or prematurity.

Choice D rationale:

"Birth history" is the most appropriate heading for recording information about the infant's delivery, including any difficulties during delivery and the fact that the baby was born prematurely. This information is relevant for understanding the infant's medical background and potential risk factors associated with prematurity.