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

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Elevate the right leg above heart level. This is contraindicated for the adolescent because elevating the leg above heart level can increase blood pressure in the injured area and worsen bleeding and swelling.

B. Prepare the adolescent for surgery. This is anticipated for the adolescent because they have an open fracture with bone displacement, which requires surgical intervention to reduce the risk of infection and complications.

C. Remove the splint. This is contraindicated for the adolescent because removing the splint can cause further damage to the bone and soft tissues and increase pain and bleeding.

D. Apply ice to the affected extremity. This is contraindicated for the adolescent because applying ice can decrease blood flow to the injured area and impair healing and sensation.

A. Radial vein of the inner arm B. Great saphenous vein of the leg C. Dorsal plexus vein of the foot D. Basilic vein of the hand

Correct Answer is A

Explanation

A. Radial vein of the inner arm. This is correct because this site is easily accessible, has good blood flow, and has less risk of complications such as infection, thrombosis, or infiltration.

B. Great saphenous vein of the leg. This is incorrect because this site is not recommended for older adults due to poor circulation, increased risk of thrombophlebitis, and difficulty in monitoring.

C. Dorsal plexus vein of the foot. This is incorrect because this site is prone to edema, infection, and injury, and can interfere with mobility and comfort.

D. Basilic vein of the hand. This is incorrect because this site is more painful, has smaller veins, and can cause nerve damage or occlusion if not inserted carefully.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client?

Correct Answer is A

Explanation

A nurse is assessing a client who has obsessive-compulsive personality disorder. Which of the following findings should the nurse expect?

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A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?

In caring for a client who requires seizure precautions, the practical nurse (PN) should ensure the ready availability of equipment to perform which procedure?