A nurse is planning care for a client who is experiencing thyroid storm triggered by a systemic infection. Which of the following interventions should the nurse plan to take?
Request a prescription for levothyroxine IV.
Administer supplemental oxygen to the client.
Cover the client with warm blankets.
Implement measures to increase the client's pulse rate.
None
None
The Correct Answer is B
Rationale:
A. Levothyroxine is used to treat hypothyroidism, not hyperthyroidism. In a Thyroid storm, thyroid hormone levels are already dangerously elevated. Giving levothyroxine would worsen the condition and increase metabolic demand further.
B. Thyroid storm causes a severe hypermetabolic state, increasing oxygen consumption and demand. Supplemental oxygen helps; prevent hypoxia, support tissues under metabolic stress, reduce risk of organ failure. Therefore making it an important supportive, priority intervention.
C. Clients in thyroid storm typically have high fever (hyperthermia). The appropriate intervention is cooling measures (cooling blankets, antipyretics), not warming. Warm blankets would worsen hyperthermia.
D. Thyroid storm causes tachycardia (very fast heart rate) and risk of arrhythmias. Increasing the pulse rate would increase risk of complications such as heart failure. Therefore the goal is to decrease heart rate (e.g., beta-blockers) and reduce cardiac workload
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) "What are you looking forward to each day?": While asking about daily expectations can provide insight into the client's coping mechanisms and hopefulness, it does not immediately address potential safety concerns. It is a helpful question for assessing the client's adjustment but not the priority if there is a concern about suicidal ideation.
B) "Can you tell me about your sleep patterns?": Sleep patterns are important for understanding overall well-being, especially during grief. However, this question is secondary to addressing the immediate risk of self-harm. Assessing sleep can come after determining if the client is having suicidal thoughts.
C) "Have you ever felt like you don't want to live anymore?": This question is crucial because it directly assesses the client's risk of suicidal ideation or self-harm. Given the client's recent loss and current symptoms, it is important to evaluate if there is a risk to their safety, making this the priority question.
D) "Are you taking any medications at this time?": While it is important to know about the client's medication use, this question does not address the immediate risk of self-harm or assess the psychological impact of the recent loss. Medication information is less urgent compared to evaluating suicidal thoughts.
Correct Answer is B
Explanation
A) Decreased deep-tendon reflexes: Decreased deep-tendon reflexes can indicate hyperkalemia, which occurs when potassium levels are too high. This is not a sign of effective potassium chloride supplementation for hypokalemia, as it suggests an imbalance in the opposite direction.
B) Regular heart rhythm: A regular heart rhythm is a key indicator that potassium levels are within the normal range. Potassium is crucial for proper cardiac function, and maintaining an adequate level helps prevent arrhythmias and supports effective heart rhythms.
C) Hypoactive bowel sounds: Hypoactive bowel sounds can be associated with various conditions, including electrolyte imbalances like hypokalemia. However, the presence of hypoactive bowel sounds does not directly indicate that potassium chloride supplementation is effective.
D) Respiratory rate 10/min: A respiratory rate of 10/min is below the normal range and can be a sign of respiratory depression or other issues. This finding does not relate to the effectiveness of potassium chloride supplements in treating hypokalemia.
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