A nurse is caring for a client who is immediately postoperative following a subtotal thyroidectomy.
Vital Signs
1100:
Temperature 37.4° C (99.4° F) Heart rate 98/min Respiratory rate 18/min
Blood pressure 128/68 mm Hg
Pulse oximetry 97% on room air
1115:
Temperature 37.8° C (100.1° F) Heart rate 110/min Respiratory rate 16/min
Blood pressure 138/74 mm Hg
Pulse oximetry 95% on room air
1130:
Temperature 38.6° C (101.5° F). Heart rate 136/min
Respiratory rate 16/min
Blood pressure 154/86 mm Hg
Pulse oximetry 95% on 2 L/min via nasal cannula
Select the 4 client findings that lead the nurse to suspect that the client is experiencing thyroid storm.
Mental status
Wound drainage
Heart rate
Pain
Blood pressure
Temperature
Correct Answer : A,C,E,F
A. This choice is correct because mental status changes, such as agitation, confusion, or delirium, are common signs of thyroid storm, which is a life-threatening complication of hyperthyroidism that occurs when there is excessive release of thyroid hormones.
B. This choice is incorrect because wound drainage is not a specific sign of thyroid storm, but rather a potential complication of any surgery that can indicate infection or bleeding.
C. This choice is correct because tachycardia, or increased heart rate, is a common sign of thyroid storm, which can result from increased metabolic demand and increased sensitivity to catecholamines.
D. This choice is incorrect because pain is not a specific sign of thyroid storm, but rather a common symptom of any surgery that can be managed with analgesics.
E. This choice is correct because hypertension, or increased blood pressure, is a common sign of thyroid storm, which can result from increased cardiac output and peripheral vascular resistance.
F. This choice is correct because hyperthermia, or increased temperature, is a common sign of thyroid storm, which can result from increased heat production and impaired heat dissipation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. Evaluating dietary intake requires nursing judgment and knowledge of nutrition and eating disorders. This task should not be delegated to an AP.
B. Incorrect. Measuring vital signs of a postoperative client requires nursing assessment and monitoring for complications. This task should not be delegated to an AP.
C. Correct. Arranging the lunch tray for a client who has a hip fracture is a routine task that does not require nursing skills or judgment. This task can be delegated to an AP.
D. Incorrect. Assessing I&O for a client who is receiving dialysis requires nursing knowledge of fluid and electrolyte balance and renal function. This task should not be delegated to an AP.
Correct Answer is A
Explanation
Choice A reason:
The statement is correct because chickenpox is highly contagious, and visiting someone with active chickenpox can put the pregnant individual at risk of contracting the infection. The recommendation is to avoid contact with individuals who have chickenpox, especially during pregnancy. The correct approach is to stay away from the infected person until they are no longer contagious (which is usually after all the sores have crusted over and dried up).
Choice B reason:
The statement Is incorrect because taking antibiotics for a viral infection is not appropriate, as antibiotics are only effective against bacterial infections, not viruses. Using antibiotics inappropriately can lead to antibiotic resistance and other potential side effects. Viral infections are generally managed with supportive care.
Choice C reason:
The statement is incorrect because handwashing is an essential infection prevention measure, but washing hands for 10 seconds with hot water may not be sufficient to remove germs effectively. The recommended duration for handwashing is at least 20 seconds with soap and water.
Choice D reason:
The statement is incorrect because cleaning a cat's litter box during pregnancy is not recommended due to the potential risk of exposure to the parasite Toxoplasma gondii, which is found in cat faeces. Toxoplasmosis can cause serious health issues in the developing foetus. It is best for pregnant individuals to avoid cleaning the litter box and have someone else do it or wear gloves and wash hands thoroughly afterward if no one else can do it.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.