The nurse is caring for a school-age child with hyperthyroidism (Graves’ disease). Which clinical manifestations should the nurse monitor that may indicate a thyroid storm? (Select all that apply)
Vomiting
Constipation
Tachycardia
Hypotension
Correct Answer : A,C
The correct answer is a. Vomiting, c. Tachycardia.
Choice A: Vomiting
Vomiting is a common symptom of thyroid storm. Thyroid storm is a life-threatening condition that occurs when the thyroid gland releases a large amount of thyroid hormone in a short period. This sudden surge in thyroid hormone can cause severe metabolic disturbances, leading to symptoms such as vomiting. Vomiting can result from the body’s attempt to cope with the excessive thyroid hormone levels, which can affect the gastrointestinal system.
Choice B: Constipation
Constipation is not typically associated with thyroid storm. In fact, hyperthyroidism, including thyroid storm, usually causes an increase in bowel movements or diarrhea due to the accelerated metabolism. Constipation is more commonly associated with hypothyroidism, where the thyroid gland is underactive and slows down bodily functions.
Choice C: Tachycardia
Tachycardia, or a rapid heart rate, is a hallmark symptom of thyroid storm. The excessive thyroid hormones increase the body’s metabolic rate, leading to an increased demand for oxygen and nutrients. To meet this demand, the heart rate increases significantly, often exceeding 140 beats per minute. This rapid heart rate can be dangerous and requires immediate medical attention.
Choice D: Hypotension
Hypotension, or low blood pressure, is not a typical symptom of thyroid storm. Instead, thyroid storm often causes hypertension (high blood pressure) due to the increased metabolic activity and the body’s heightened demand for oxygen and nutrients. The cardiovascular system responds by increasing blood pressure to ensure adequate blood flow to vital organs.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Walnuts are a source of protein and contain phenylalanine, an amino acid that individuals with phenylketonuria (PKU) must limit in their diet. While nuts can be a healthy snack for most people, they are not suitable for those with PKU due to their high phenylalanine content. Therefore, walnuts are not the best choice for children with PKU.
Choice B reason:
Cow’s milk is another source of protein and contains significant amounts of phenylalanine. Dairy products, including milk, cheese, and yogurt, are generally high in protein and should be avoided by individuals with PKU. Consuming cow’s milk can lead to elevated levels of phenylalanine in the blood, which can be harmful to children with PKU.
Choice C reason:
Bananas are a fruit that contains very low levels of phenylalanine. Fruits and vegetables are generally safe for individuals with PKU as they are low in protein and phenylalanine. Bananas, in particular, are a good option for children with PKU as they provide essential nutrients without contributing to high phenylalanine levels.
Choice D reason:
Diet soda with aspartame should be avoided by individuals with PKU because aspartame is an artificial sweetener that contains phenylalanine. Consuming products with aspartame can lead to an increase in phenylalanine levels in the blood, which can be harmful to those with PKU. Therefore, diet soda with aspartame is not a suitable choice for children with PKU.
Correct Answer is D
Explanation
Choice A reason:
Peanuts are not recommended for infants, especially those under one year of age, due to the risk of choking and potential allergies. Additionally, peanuts are not a significant source of iron and would not be effective in preventing iron deficiency anemia in infants. Therefore, this choice is not appropriate for preventing iron deficiency anemia in a 6-month-old infant.
Choice B reason:
Iron (ferrous sulfate) tablets are not typically recommended for infants unless prescribed by a healthcare provider. Infants who are exclusively breastfed or partially breastfed should receive iron supplementation starting at 4-6 months of age, but this is usually in the form of liquid drops rather than tablets. It is important to follow the guidance of a healthcare provider when administering iron supplements to infants.
Choice C reason:
Sautéed liver is a rich source of iron, but it is not suitable for a 6-month-old infant. Introducing solid foods to infants should be done gradually, starting with iron-fortified cereals and pureed fruits and vegetables. Liver can be introduced later as part of a balanced diet, but it is not the first choice for preventing iron deficiency anemia in a young infant.
Choice D reason:
Iron-fortified baby cereal is the recommended choice for preventing iron deficiency anemia in a 6-month-old infant who is still breastfeeding. These cereals are specifically designed to provide the necessary iron that infants need as they transition to solid foods. Starting with iron-fortified cereals helps ensure that the infant receives adequate iron to support healthy growth and development.
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