A client has been diagnosed with hyperthyroidism. Which signs and symptoms may indicate thyroid storm, a complication of this disorder?

Choice A reason: Alcohol abuse is a significant risk factor for ICU delirium, as withdrawal or chronic effects disrupt brain function. This aligns with neurological risk assessment, making it the correct problem the nurse would identify as a key contributor to delirium risk.

Choice B reason: Impaired communication may result from delirium but isn’t a primary risk factor. Alcohol abuse is more causative, making this incorrect, as it’s less significant than the nurse’s focus on a direct risk like alcohol-related neurological changes.

Choice C reason: Type 2 diabetes may contribute to delirium via hyperglycemia but is less direct than alcohol abuse, which triggers withdrawal. This is incorrect, as it’s a secondary factor compared to the nurse’s priority risk factor for ICU delirium.

Choice D reason: Anxiety can exacerbate delirium but is less causative than alcohol abuse, which has a stronger neurological impact. This is incorrect, as it’s not the primary risk factor the nurse would identify for delirium in the ICU setting.

Choice A reason: Measuring the ankle-brachial index assesses perfusion but delays addressing an absent pedal pulse, suggesting graft occlusion. Contacting the provider is urgent, making this incorrect, as it’s not the nurse’s first action for a critical post-surgical finding.

Choice B reason: Rechecking the pulse in 30 minutes delays intervention for an absent pulse, risking limb ischemia. Notifying the provider is priority, making this incorrect, as it postpones the nurse’s action to address a potential surgical complication immediately.

Choice C reason: Administering an anticoagulant requires an order and doesn’t address an absent pulse, indicating possible graft failure. Contacting the provider is critical, making this incorrect, as it’s inappropriate compared to the nurse’s need for urgent medical evaluation.

Choice D reason: Contacting the provider is the priority for an absent pedal pulse post-bypass surgery, as it suggests graft occlusion, a surgical emergency. This aligns with post-operative protocols, making it the correct action for the nurse to take immediately.