While assessing a client with Graves' disease, the nurse notes that the client's temperature has risen 1 ° F. Which action should the nurse take first?
a. Turn the lights down and shut the client's door.
b. Call for an immediate electrocardiogram (ECG).
c. Calculate the client's apical-radial pulse deficit.
d. Administer a dose of acetaminophen (Tylenol).
ANS: A
A temperature increase of 1 ° F may indicate the development of thyroid storm, and the provider needs to be notified. But before notifying the provider, the nurse should take measures to reduce environmental stimuli that increase the risk of cardiac complications. The nurse can then call for an ECG. The apical-radial pulse deficit would not be necessary, and Tylenol is not needed because the temperature increase is due to thyroid activity.
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