Which of the following assessment findings characterize thyroid storm? a) increased body temperature, decreased pulse, and increased blood pressure b) increased body temperature, increased pulse, and increased blood pressure c) increased body temperature, decreased pulse, and decreased blood pressure d) increased body temperature, increased pulse, and decreased blood pressure b) increased body temperature, increased pulse, and increased blood pressure Thyroid storm is characterized by SNS activation. Thyroid hormones potentiate effects of cathecolamines (epinephrine/norepinephrine). Therefore, all vital signs will be increased. The nurse is planning care for a client with hyperthyroidism. Which of the following nursing interventions are appropriate? Select all that apply a) instill isotonic eye drops as necessary b) provide several, small, well-balanced meals c) provide rest periods d) keep environment warm e) encourage frequent visitors and conversation f) weigh the client daily a, b, c, and f (a) The client with hyperthyroidism may experience exopthalmos. This requires instillation of eye drops to prevent dryness and ulceration of the cornea. (b and f) The client experiences weight loss because of hypermetabolism. Several, small, wellbalanced meals are given to improve nutritional status of the client and daily weights should be monitored. Weight is the most objective indicator of nutritional status. (c) The client is usually exhausted due to restlessness and agitation. Frequent rest periods help the client regain energy. After thyroidectomy, which of the following is the priority assessment to observe laryngeal nerve damage? a) hoarseness of voice b) difficulty in swallowing c) tetany d) fever a) hoarseness of voice Laryngeal nerve damage is manifested by severe hoarseness of voice of "whispery voice". When caring for a male client with diabetes insipidus, nurse Juliet expects to administer: a. vasopressin (Pitressin Synthetic) b. furosemide (Lasix). c. regular insulin. d. 10% dextrose. a. vasopressin (Pitressin Synthetic) Because diabetes insipidus results from decreased antidiuretic hormone (vasopressin) production, the nurse should expect to administer synthetic vasopressin for hormone replacement therapy. Furosemide, a diuretic, is contraindicated because a client with diabetes insipidus experiences polyuria. Insulin and dextrose are used to treat diabetes mellitus and its complications, not diabetes insipidus. Nurse Ronn is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse would expect to find: a. Hypotension. b. Thick, coarse skin. c. Deposits of adipose tissue in the trunk and dorsocervical area. d. Weight gain in arms and legs. c. Deposits of adipose tissue in the trunk and dorsocervical area Because of changes in fat distribution, adipose tissue accumulates in the trunk, face (moonface), and dorsocervical areas (buffalo hump). Hypertension is caused by fluid retention. Skin becomes thin and bruises easily because of a loss of collagen. Muscle wasting causes muscle atrophy and thin extremities. For the first 72 hours after thyroidectomy surgery, nurse Jamie would assess the female client for Chvostek's sign and Trousseau's sign because they indicate which of the following? a. Hypocalcemia b. Hypercalcemia c. Hypokalemia d. Hyperkalemia a. Hypocalcemia The client who has undergone a thyroidectomy is at risk for developing hypocalcemia from inadvertent removal or damage to the parathyroid gland. The client with hypocalcemia will exhibit a positive Chvostek's sign (facial muscle contraction when the facial nerve in front of the ear is tapped) and a positive Trousseau's sign (carpal spasm when a blood pressure cuff is inflated for a few minutes). These signs aren't present with hypercalcemia, hypokalemia, or hyperkalemia. An incoherent female client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and pretibial area. Knowing that these findings suggest severe hypothyroidism, nurse Libby prepares to take emergency action to prevent the potential complication of: a. Thyroid storm. b. Cretinism. c. Myxedema coma. d. Hashimoto's thyroiditis. c. Myexedema coma. Severe hypothyroidism may result in myxedema coma, in which a drastic drop in the metabolic rate causes decreased vital signs, hypoventilation (possibly leading to respiratory acidosis), and nonpitting edema. Thyroid storm is an acute complication of hyperthyroidism. Cretinism is a form of hypothyroidism that occurs in infants. Hashimoto's thyroiditis is a common chronic inflammatory disease of the thyroid gland in which autoimmune factors play a prominent role.
