A nurse is caring for a client who has Graves' disease. Which of the following findings should indicate to the nurse that the client is developing a thyroid storm?

Tachycardia

Hypotension

Neck pain

Respiratory depression

Answer and Explanation

The Correct Answer is A

A. Tachycardia: This is correct. Tachycardia is one of the hallmark signs of thyroid storm, a life-threatening complication of hyperthyroidism (often seen in Graves' disease.. The excessive thyroid hormone leads to severe metabolic disturbances, including an increased heart rate.

B. Hypotension: Hypotension is not typically a feature of thyroid storm. In fact, thyroid storm is more commonly associated with hypertension due to the increased heart rate and metabolic activity.

C. Neck pain: Neck pain is not a common symptom of thyroid storm. Neck pain might be related to other conditions, such as thyroiditis or a goiter, but not specifically thyroid storm.

D. Respiratory depression: Respiratory depression is not a typical symptom of thyroid storm. On the contrary, thyroid storm often leads to symptoms like hyperventilation, not depressed breathing.

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Correct Answer is B

Explanation

A. Erythema is a sign of infection or irritation, not fluid infiltration. Fluid infiltration typically does not cause redness or inflammation.

B. Edema is correct. Fluid infiltration occurs when the IV catheter becomes displaced and the fluid leaks into the surrounding tissue, causing swelling (edema. at the insertion site.

C. Blood would suggest either an accidental dislodging of the catheter or a complication such as hematoma formation, but it is not a sign of fluid infiltration.

D. Pruritus (itching) is typically associated with an allergic reaction, not fluid infiltration.

A. Communicate with personnel about the need for prophylaxis. B. Place a mask on the client. C. Contact those who live with the client. D. Notify the local health department.

Correct Answer is B

Explanation

A. "Communicate with personnel about the need for prophylaxis" is incorrect. While it is important to consider prophylaxis for those who may have been exposed to tuberculosis, the first priority is to minimize the risk of transmission from the client to others.

B. "Place a mask on the client" is correct. Placing a mask on the client is the first step in preventing the spread of tuberculosis. This helps contain respiratory droplets that could transmit the bacteria to others.

C. "Contact those who live with the client" is incorrect. While it is important to contact close contacts to assess their risk, this action comes after implementing infection control measures, such as placing a mask on the client.

D. "Notify the local health department" is incorrect. While the health department must be notified about a tuberculosis diagnosis, the immediate priority is to protect others from exposure by masking the client and using appropriate isolation precautions.

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A nurse is caring for a client who has Graves' disease. Which of the following findings should indicate to the nurse that the client is developing a thyroid storm?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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