A nurse is collecting data from a client who is receiving IV therapy. The nurse suspects fluid infiltration. Which of the following findings should the nurse expect at the insertion site?

A. Decreased body temperature is incorrect. A thyroid storm is characterized by a hypermetabolic state, so a decreased body temperature would be inconsistent with the condition. In fact, patients with thyroid storm typically have increased body temperature (fever).

B. Increased incisional drainage is incorrect. While increased drainage could indicate a wound infection or other surgical complications, it is not a primary indicator of thyroid storm, which involves a hyperactive thyroid response.

C. Hypertension is correct. Thyroid storm is a severe, acute exacerbation of hyperthyroidism, and it is associated with hypertension, tachycardia, fever, and other symptoms of sympathetic nervous system overactivity.

D. Bradycardia is incorrect. Bradycardia would be expected in conditions like hypothyroidism, not thyroid storm. Thyroid storm typically presents with tachycardia, which is a hallmark sign.

A. "This must be very frightening for you. Let's talk more about it.": This response demonstrates empathy and validation of the client's feelings, which can help build trust. It acknowledges the client's emotional state while not challenging or confronting their delusion directly. This approach helps maintain rapport while encouraging the client to express themselves.

B. "What makes you think the staff is following you?": This response could be perceived as questioning the validity of the client's experience, which may feel confrontational or invalidating. It is not the best approach for engaging a client with paranoid delusions.

C. “Why do you feel the staff is the FBI?": This question could also challenge the client's delusion and inadvertently reinforce their sense of being persecuted. Asking such a question might escalate anxiety rather than calm the client.

D. "The psychiatric staff is not FBI. They are here to help you.": While this response is factually correct, it may be perceived as dismissive of the client's experience. Confronting the delusion directly is generally not helpful and can increase the client's feelings of mistrust.