A patient with Graves' disease is brought to the emergency department by her husband. He says that the couple have both had the flu and that she "has not been able to keep anything down for about 3 days."

Question

The patient has a temperature of 103ºF, heart rate is 124bpm, respiratory rate 20, and blood pressure 150/88 mmHg. She complains of severe nausea and is very agitated. Which actions should the nurse take? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Have both the patient and the husband put on isolations masks.
2. Notify the physician that another patient with possible influenza has been admitted to the ED.
3. Place the patient on a cardiac monitor.
4. Start an intravenous access device according to emergency protocol.
5. Stay with the patient while another nurse notifies the physician of the patient's condition.

Answer 1

3,4,5
Rationale 1: There is no indication that this patient should be further stressed by being asked to wear an isolation mask.
Rationale 2: The nurse should not assume this patient's symptomology is related to influenza.
Rationale 3: This patient should be monitored for the development of atrial fibrillation or other cardiac dysrhythmia. Thyroid storm may be occurring, as the patient is stressed and has not been able to take thyroid medication for 3 days.
Rationale 4: This patient is likely to need venous access for fluids and medications. The nurse should follow emergency protocols to insert this device. Thyroid storm may be occurring as the patient is stressed and has not been able to take thyroid medication for 3 days.
Rationale 5: Thyroid storm may be occurring as the patient is stressed and has not been able to take thyroid medication for 3 days. This is an emergent condition and treatment should begin immediately.