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: Administering penicillin.
Choice A rationale:
Imposing strict bed rest for 4 to 6 weeks. This choice is not the most appropriate therapeutic management for rheumatic fever. While rest is important during the acute phase, strict bed rest for 4 to 6 weeks is excessive and could lead to physical deconditioning and psychological distress for the child.
Choice B rationale:
Administering corticosteroids if chorea develops. This choice is relevant to the management of rheumatic fever but is not the primary treatment. Chorea is a movement disorder that can occur as a complication of rheumatic fever. Corticosteroids may be used to manage chorea symptoms, but they are not the mainstay of treatment for rheumatic fever itself.
Choice C rationale:
Administering penicillin. This is the correct choice. Penicillin is the mainstay of treatment for rheumatic fever. It helps eradicate the group A streptococcal infection that triggers the inflammatory response leading to rheumatic fever. Penicillin is essential to prevent further complications such as rheumatic heart disease.
Choice D rationale:
Avoiding salicylates (aspirin). This choice is also relevant to the management of rheumatic fever. Salicylates, including aspirin, are used to relieve symptoms and reduce inflammation. However, in children with acute rheumatic fever, salicylates are contraindicated due to the risk of developing Reye's syndrome, a serious condition that affects the brain and liver.
Correct Answer is D
Explanation
The correct answer is choice D: Sex can be presented as a normal part of growth and development.
Choice A rationale:
Children in 5th grade are generally around 10 to 11 years old, which means they are approaching puberty and experiencing physical changes. While it might be tempting to think that they are too young for sex education, it's important to acknowledge that they are at an age where their bodies are undergoing significant transformations. Providing them with age-appropriate sex education can empower them to understand these changes and navigate them safely.
Choice B rationale:
Correct terminology should not be reserved solely for older children. Using accurate and age-appropriate terminology when discussing topics related to sex and development is crucial. Children in 5th grade are capable of understanding basic anatomical terms and concepts, which can help them better comprehend their own bodies and the changes they are experiencing.
Choice C rationale:
Encouraging children to ask questions is an essential part of sex education. s reflect curiosity and a desire to learn. Discouraging questions can lead to misinformation and misunderstandings. Open dialogue about sex and development can help dispel myths and promote healthy attitudes toward these topics.
Choice D rationale:
Presenting sex as a normal part of growth and development is the foundation of comprehensive and age-appropriate sex education. Children in 5th grade are entering a stage of life where they might start experiencing sexual curiosity and have questions about their bodies. Addressing these questions in a respectful and factual manner can help them develop a healthy understanding of their own sexuality and promote safe behaviors.
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