Which assessment finding for a 33-year-old female patient admitted with Graves' disease requires the most rapid intervention by the nurse?
a. Bilateral exophthalmos
b. Heart rate 136 beats/minute
c. Temperature 103.8° F (40.4° C)
d. Blood pressure 166/100 mm Hg
ANS: C
The patient's temperature indicates that the patient may have thyrotoxic crisis and that interventions to lower the temperature are needed immediately. The other findings also require intervention but do not indicate potentially life-threatening complications.
You might also like to view...
Issues affecting academic integrity include:
a. plagiarism and cheating. c. editing and forgery. b. cheating and editing. d. forgery and consulting.
The school nurse is called to the playground to attend to a child who has had a tooth knocked out during a playground fight. Which of the following would be the best action for the nurse to take?
a. Have the child gargle with hot salt water and put the tooth in an envelope so the child can put it under his or her pillow. b. Apply an ice pack to the side of the face there the tooth came out, and have the child rinse the mouth several times with ice-cold water. c. Gently rinse the tooth with water, put the tooth back into the socket, and call the caregivers to take the child to the dentist. d. Call the parents immediately so they can contact the dentist to find out what the dentist wants them to do.
The nurse is assisting an intellectually impaired child to eat. Which of the following is a recommended guideline for this procedure?
A) Place the child in a semisitting position with the head flexed slightly backward. B) Teach or remind the child to chew and, if necessary, manipulate the jaw up and down. C) Place food in the center of the mouth, not on the side, and do not rush. D) Keep the atmosphere quiet and, if possible, feed the child alone.
Hemiparesis occurs simultaneously on both sides of the body.
Answer the following statement true (T) or false (F)