A nurse is teaching a client who has Graves' disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse include in the teaching?

C. The blood pressure readings show significant variability (164/80 mm Hg at 1000, 176/82 mm Hg at 1015, and 110/62 mm Hg at 1200). These fluctuations, especially the higher readings, indicate potential instability and require close monitoring and possibly intervention.
D. The client's pain level is described as 7/10 initially (1000) and decreases to 5/10 after nitroglycerin (1200). Although the pain has decreased, ongoing assessment is necessary to ensure it does not worsen or change in nature.
E. The 12-lead electrocardiogram (ECG) shows tachycardia with ST segment elevation and T wave changes, which are indicative of myocardial ischemia or infarction. This finding requires immediate attention as it suggests ongoing cardiac damage.
G. The troponin T level is elevated at 0.40 ng/mL (normal is less than 0.1 ng/mL). Troponin elevation indicates myocardial injury or infarction and confirms the seriousness of the cardiac event. This finding requires immediate attention to assess the extent of myocardial damage and guide further treatment.

Incorrect Choices
A. While it is slightly elevated, it is not significantly outside the normal range and does not suggest immediate danger or require urgent intervention in the context of the acute cardiac issue. However, monitoring blood glucose levels is important for overall management, especially in a client with diabetes mellitus.
B. The assessment of bowel sounds being present in all 4 quadrants is a normal finding and indicates normal gastrointestinal function. While bowel sounds are important for assessing gastrointestinal health, they are not immediately pertinent to the acute cardiac issue described in the scenario.
F. The nurse notes that lung sounds are clear to auscultation in all lobes, which is a normal finding. Clear lung sounds suggest normal respiratory function and do not require immediate attention in the context of the acute cardiac event described.

A Advancing the weaker leg forward to the quad cane first indicates that the client understands the proper sequence of using the cane to support their weaker side. This action provides stability and reduces the risk of falls or imbalance.

B. Holding the cane with the opposite hand of the weaker side (right hand, in this case) is crucial to provide proper support and balance while walking. This distributes weight evenly and enhances stability.

C. Taking a step with the stronger foot first does not effectively support the weaker side and can lead to imbalance or falls, especially for a client with left-sided weakness.

D. While moving the cane ahead with each step is necessary, the distance of two feet is not specified in proper cane use. The cane should move forward incrementally with each step to maintain stability and support.