The nurse is reviewing the client's medical record.

A nurse is reviewing the client's diagnostic results and vital signs. Which of the following actions should the nurse take? Select all that apply.

Rationale for Correct Choices

• Hyperthyroidism: The client presents with classic signs of thyrotoxicosis including tachycardia, hypertension, fever, tremors, agitation, diarrhea, weight loss despite good appetite, and insomnia. Laboratory findings show elevated T3 and T4 with suppressed TSH, confirming a hyperthyroid state. The acute presentation following recent influenza suggests possible thyroid storm, a life-threatening exacerbation requiring immediate intervention.

• Place client on telemetry: Hyperthyroidism and thyroid storm increase the risk for cardiac dysrhythmias such as atrial fibrillation, supraventricular tachycardia, and other life-threatening arrhythmias. Continuous cardiac monitoring allows early detection and prompt management of any rhythm disturbances.

• Initiate hydration therapy: Clients with hyperthyroidism may have increased metabolic rate, fever, diarrhea, and insensible fluid losses, leading to dehydration. Aggressive hydration helps maintain perfusion, correct electrolyte imbalances, and prevent complications such as hypotension and renal impairment.

• Cardiac dysrhythmias: Hyperthyroid clients are at high risk for tachyarrhythmias due to increased sympathetic activity and elevated circulating thyroid hormones. Monitoring for dysrhythmias provides early warning of complications and guides the need for pharmacologic interventions like beta-blockers.

• Neurological status: Thyroid storm can rapidly alter mental status, leading to agitation, delirium, or coma. Continuous monitoring ensures timely detection of neurological deterioration and supports rapid intervention to prevent complications such as seizures or altered consciousness.

Rationale for Incorrect Choices

• Hypoparathyroidism: Hypoparathyroidism primarily causes hypocalcemia, which is not observed here. The client’s calcium levels are within normal limits, and the presenting symptoms are more consistent with thyrotoxicosis rather than low parathyroid hormone activity.

• Hyperparathyroidism: Hyperparathyroidism typically presents with hypercalcemia, bone pain, kidney stones, and fatigue. This client’s calcium and phosphorus levels are normal, and symptoms such as tachycardia, diarrhea, and tremors point toward thyroid rather than parathyroid pathology.

• Hypothyroidism: Hypothyroidism presents with bradycardia, fatigue, weight gain, cold intolerance, constipation, and dry skin. This client exhibits the opposite—tachycardia, weight loss, diarrhea, tremors, and hyperthermia—making hypothyroidism inconsistent with the findings.

• Provide nutritional support: While nutrition is important, it is not the immediate priority in an acute thyroid storm. Initial interventions should focus on stabilizing cardiovascular function, hydration, and monitoring for life-threatening complications.

• Monitor for hypoglycaemia: Hyperthyroidism increases metabolic demand and gluconeogenesis rather than causing hypoglycemia. Routine glucose monitoring is not a priority unless there are additional risk factors such as concurrent diabetes or insulin therapy.

• Check for Chvostek and Trousseau signs: These tests assess for hypocalcemia seen in hypoparathyroidism, which is not indicated in this client. Calcium levels are normal, so these assessments are not relevant for the current acute condition.

• Phosphorus levels: Phosphorus is primarily relevant in parathyroid disorders, not in acute hyperthyroidism. The client’s phosphorus is within normal limits, and monitoring is not essential for thyroid storm management.

• Weight gain: Thyroid storm often leads to rapid weight loss due to increased metabolic rate. Monitoring for weight gain is not relevant in this acute presentation and does not guide immediate nursing interventions.

• Calcium levels: Calcium levels are normal, and acute hyperthyroidism does not typically alter calcium homeostasis significantly. Monitoring calcium is not a priority unless there is a preexisting parathyroid or electrolyte disorder.

A. "Wear cotton rather than nylon socks.": Cotton socks help keep the feet dry by absorbing moisture, reducing the risk of fungal infections and skin breakdown. They also allow better air circulation than nylon, which can trap moisture and increase friction. This instruction supports protective foot care for clients with diabetes.

B. "Use a heating pad to keep your feet warm at night.": Heating pads should be avoided because clients with diabetes may have peripheral neuropathy and reduced sensation. Using heat sources increases the risk of burns or skin injury without the client realizing it, making this unsafe for foot care.

C. "Wear loose fitting slippers around the house.": Loose footwear can cause friction, slipping, and inadequate support, increasing the risk of injury. Diabetic clients should wear well-fitting, closed-toe shoes to protect the feet from trauma and prevent skin breakdown.

D. "Wash your feet twice per day with antibacterial soap and hot water.": Hot water can burn insensate feet, and antibacterial soaps can dry and irritate the skin. Clients should wash their feet once daily with warm water and mild soap to maintain skin integrity while avoiding injury or excessive dryness.