# A client with poorly controlled Graves disease presents with temperature 40.1 C, HR 168, BP 162/96, agitation, and new atrial fibrillation. Which interventions should the nurse anticipate as priority? Select all that apply.

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375016&lang=en  
> language: en  
> subject: Physiological Adaptation  
> category: PA

## Question

A client with poorly controlled Graves disease presents with temperature 40.1 C, HR 168, BP 162/96, agitation, and new atrial fibrillation. Which interventions should the nurse anticipate as priority? Select all that apply.

1

Give aspirin as an antipyretic and anti-inflammatory agent to manage symptoms

2

Administer IV propranolol or esmolol to control adrenergic symptoms and rate

3

Give iodine (Lugol or potassium iodide) at least 1 hour AFTER starting antithyroid drug

4

Apply cooling measures and acetaminophen avoiding aspirin

5

Begin propylthiouracil or methimazole as antithyroid therapy

## Explanation

Thyroid storm management: beta-blocker (propranolol/esmolol) for sympathetic crisis, antithyroid drug (PTU preferred in pregnancy and storm because it also blocks T4-to-T3 conversion; methimazole otherwise), iodine to block hormone release given AT LEAST 1 HOUR after antithyroid drug (otherwise iodine would be substrate), glucocorticoids (hydrocortisone 100 mg q8h) for adrenal stress and conversion blockade, active cooling, and treat precipitant (infection, surgery). ASPIRIN is CONTRAINDICATED — it displaces thyroid hormone from thyroid binding globulin worsening storm. Acetaminophen is the antipyretic of choice.

## In-depth explanation

Burch-Wartofsky over 45 = thyroid storm likely. Memorize the sequence: beta-blocker → antithyroid → wait 1 hour → iodine → steroid → cooling.

## Clinical scenario

Burch-Wartofsky score 65 (greater than 45 is highly suggestive of storm). Last methimazole dose missed for 4 days due to GI illness.

## Key concepts

- **thyroid storm** — Decompensated hyperthyroidism with high mortality if untreated.
- **Burch-Wartofsky score** — Diagnostic score for thyroid storm; over 45 highly suggestive.
- **propylthiouracil** — Antithyroid drug also blocking T4-to-T3 conversion; preferred in storm and pregnancy first trimester.

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