Question

Admission assessment data for a client on the telemetry unit includes the following: Reports of racing heart and nervousness that have occurred several times before. Telemetry monitor: sinus tachycardia Heart rate: 130/bpm Skin: warm and dry Eyes: appear bulging What is the most important initial nursing action?

Answer 1

The initial nursing action is to assess and monitor the patient's vital signs, focusing on the cardiovascular status due to the reported sinus tachycardia, and consider potential causes such as hyperthyroidism or autonomic nervous system disorders.

Step-by-step explanation:

The most important initial nursing action for a client on the telemetry unit with symptoms of a racing heart, nervousness, warm and dry skin, and bulging eyes is to perform an assessment of the patient's current symptoms and vital signs, particularly focusing on the cardiovascular status due to the reported sinus tachycardia with a heart rate of 130/bpm. Promptly assessing and monitoring the patient's vital signs will help determine the severity and potential causes of the tachycardia, which may include hyperthyroidism, autonomic nervous system disorders, or extreme stress. Further testing and interventions should be based on the assessment findings and may involve additional diagnostic tests, medication administration, or emergency interventions if necessary.

Answer 2

The nurse should stand behind the client and palpate the cricothyroid area.

Step-by-step explanation:

The client presents symptoms of hyperthyroidism, an autoimmune disease where the thyroid gland produces an excess of its hormone causing palpitations, bulging eyes, an increase in temperature, trembling hands, nervousness, panic attacks, insomnia, and weight loss.

When the thyroid gland overproduces the thyroid hormone, it increases its size. A nurse can check the size by palping the cricothyroid area, which is where the thyroid gland is.