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 A
Explanation
A) Administer dantrolene sodium IV: Dantrolene sodium is the treatment of choice for malignant hyperthermia. It acts as a muscle relaxant by inhibiting calcium release from the sarcoplasmic reticulum in skeletal muscles, which helps to halt the hypermetabolic crisis.
B) Monitor client for rapid decrease in heart rate: While monitoring vital signs is essential, a rapid decrease in heart rate is not a typical manifestation of malignant hyperthermia. The nurse should primarily focus on interventions to reduce hyperthermia and stabilize the client's condition.
C) Infuse chilled lactated Ringer's IV: Infusing chilled IV fluids can help lower the body temperature in malignant hyperthermia. However, this intervention is supportive and secondary to the administration of dantrolene sodium, which directly addresses the underlying pathophysiology.
D) Provide oxygen at 12 L/min via Venturi mask: Providing high-flow oxygen is necessary to manage hypoxia and metabolic acidosis associated with malignant hyperthermia. Nonetheless, this action is secondary to administering dantrolene sodium, which is crucial to stopping the hyperthermic crisis.
Correct Answer is B,C,E,A,D
Explanation
B. Attach the spacer.: Attaching the spacer first ensures that the inhaler is properly connected and ready for use.
C. Shake the inhaler.: Shaking the inhaler is essential to mix the medication thoroughly before use.
E. Place lips around the mouthpiece.: Placing the lips around the mouthpiece is done while the inhaler is ready to be activated.
A. Press down on the canister top.: Pressing the canister releases the medication into the spacer, which the client will then inhale.
D. Hold breath for 10 seconds.: Holding the breath allows the medication to be fully absorbed into the lungs.
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