A nurse is caring for a client who has Graves' disease and is experiencing a thyroid storm. Which of the following actions is the nurse's priority?

Provide a cooling blanket.

Monitor the client's cardiac rhythm.

Administer 0.9% sodium chloride IV.

Obtain the client's blood glucose.

Answer and Explanation

The Correct Answer is B

A.   While a cooling blanket may be indicated to reduce fever associated with a thyroid storm, the priority lies in monitoring the cardiac rhythm for potential life-threatening complications such as tachycardia or arrhythmias.
B.   Thyroid storm can precipitate severe cardiac complications, making continuous monitoring of the client's cardiac rhythm imperative to detect any abnormalities promptly.
C.   Administering IV fluids may be necessary to address dehydration, but it is not the priority over monitoring the cardiac rhythm.
D.   While monitoring blood glucose levels is important, it is not the immediate priority in managing a thyroid storm.

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Correct Answer is A

Explanation

A. Basal body temperature should be measured immediately upon waking and before any physical activity to ensure accuracy in detecting the slight temperature rise after ovulation.
B. Temperature taken after getting out of bed may not accurately reflect the basal body temperature.
C. Basal body temperature is best measured in the morning.

D. The timing here still allows for too much activity before measuring temperature, which can affect the reading.

A. Pedal pulses B. Breath sounds C. Heart rate D. Movement of right foot E. Respiratory rate F. Pulse oximetry

Correct Answer is ["B","C","E","F"]

Explanation

A. While it's important to assess pedal pulses regularly, there is no indication in the scenario that the pedal pulses are abnormal or require immediate follow-up. The description mentions bilateral pedal pulses being present and intact throughout both days, suggesting no acute issues with peripheral circulation.

B. Crackles heard at the bases indicate possible pulmonary complications such as atelectasis or pneumonia, requiring further assessment and intervention.
C. A heart rate of 112/min indicates tachycardia, which could be a sign of pain, anxiety, or underlying cardiovascular issues. Further evaluation is needed to determine the cause.
D. The scenario states that the movement and sensation of the right foot are intact, with warm skin and no change in pigmentation. There are no signs of compromised neurovascular status in the right foot based on the provided information, so immediate follow-up for this finding is not necessary.
E. A respiratory rate of 28/min is elevated, suggesting respiratory distress or inadequate ventilation. Prompt assessment and intervention are necessary to address any respiratory issues.
F. A pulse oximetry reading of 88% on room air indicates hypoxemia, which requires immediate attention to ensure adequate oxygenation. Further assessment and intervention are needed to improve oxygen saturation levels.

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A nurse is caring for a client who has Graves' disease and is experiencing a thyroid storm. Which of the following actions is the nurse's priority?

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Naxlex Comprehensive Predictor Exams

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