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?
Explanation & Rationale
A. Turn the lights down and shut the client's door: Increased body temperature can be an early sign of thyroid storm. Decreasing environmental stimuli (such as light and noise) helps lower stress on the body and may prevent exacerbating the symptoms. B. Call for an immediate electrocardiogram (ECG): While thyroid storm can cause tachycardia and arrhythmias, an elevated temperature by 1° F alone does not warrant an ECG. The priority is to manage the potential triggers for the rise in temperature first. C. Administer a dose of acetaminophen: A mild temperature increase in Graves' disease could indicate the beginning of thyroid storm, which requires more immediate interventions like cooling measures and possibly antithyroid medications. D. Calculate the client's apical-radial pulse deficit: Monitoring for a pulse deficit could be important if the client is experiencing arrhythmias or tachycardia, but the priority is to address the rising temperature and environmental factors, as these can escalate into a thyroid storm.