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.
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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Related Questions
Correct Answer is C
Explanation
A. Using a child as an interpreter can be inappropriate and may not ensure accurate communication, especially for sensitive topics such as medical history and symptoms.
B. While involving the client's partner may seem helpful, it may not ensure accurate translation, and the partner may not be proficient in medical terminology.
C. Requesting a female interpreter through the facility ensures accurate and confidential communication while respecting the client's cultural preferences and privacy.
D. While asking a nursing student who speaks the same language as the client may seem convenient, it may not ensure accurate translation, and the student may not have the necessary training in medical interpretation.
Correct Answer is A
Explanation
A: Swallowing ability is crucial because ALS often leads to dysphagia, which can cause weight loss due to difficulty eating and the risk of aspiration.
B: Changes in appetite are important but secondary to physical ability to eat safely.
C: While knowing about prescribed medications is necessary, it does not directly address the issue of weight loss as critically as swallowing ability.
D: Fluid intake is important but the priority is assessing the ability to swallow safely, which directly impacts nutritional status.
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