A nurse is caring for a client who reports increased anxiety and nervousness, heat intolerance, and unintentional weight loss. Blood testing reveals decreased thyroid-stimulating hormone (TSH), elevated thyroxine (T4), and elevated triiodothyronine (T3) levels. Which of the following vital sign abnormalities does the nurse anticipate?
Hypotension
Tachycardia
Slow respiratory rate
Decreased body temperature
The Correct Answer is B
A. Hypotension: Hyperthyroidism typically causes increased cardiac output and can lead to normal or elevated blood pressure, not hypotension.
B. Tachycardia. Elevated thyroid hormones increase metabolic rate and sympathetic nervous system activity, leading to tachycardia.
C. Slow respiratory rate: There is no direct effect of hyperthyroidism on respiratory rate.
D. Decreased body temperature: Hyperthyroidism is associated with increased metabolism, which can lead to heat intolerance and increased body temperature, not decreased.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Lethality of the method and availability of means. Assessing the method and means helps determine the immediacy and seriousness of the threat. Knowing the lethality of the method and whether the means are readily available informs the level of intervention needed to keep the client safe.
B. Client's educational and economic background: While socioeconomic factors can influence mental health, they are not immediate priorities in a suicidal crisis.
C. Client's insight into the reasons for the decision: Insight is important for understanding motivations but is secondary to immediate safety concerns.
D. Quality of the client's social support: Social support is crucial but is secondary to assessing imminent risk of harm.
Correct Answer is C
Explanation
A. Coma: Possible in severe cases but not universally anticipated.
B. Hypothermia: Incorrect. Thyroid storms typically causes hyperthermia, not hypothermia.
C. Tachycardia. Tachycardia is a hallmark of thyroid storms due to excessive thyroid hormone levels stimulating the heart. Increased metabolic rate and sympathetic activity lead to rapid heart rate.
D. Fruity smelling breath: Not typically associated with thyroid storm.
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