A client is experiencing a thyroid storm precipitated by a right lower lobe pneumonia. The vital signs are: HR-140/min; RR-28, B/P-196/54; T-101.4°F, Pulse Oximetry-96%. What action should the nurse take?

Choice A reason: Increasing calcium in the diet is not the most important instruction for a client with hypertension. Calcium is a mineral that helps maintain bone health and muscle contraction, but it does not have a significant effect on blood pressure. The nurse should advise the client to limit sodium, fat, and alcohol intake, and to eat more fruits, vegetables, and whole grains.

Choice B reason: Obtaining blood pressure checks twice a year is not the most important instruction for a client with hypertension. This frequency is too low for a client who has a chronic condition that requires close monitoring and treatment. The nurse should advise the client to check their blood pressure regularly, preferably at home, and to report any abnormal readings to their health care provider.

Choice C reason: Monitoring weight on a weekly basis is not the most important instruction for a client with hypertension. Weight is a factor that can influence blood pressure, but it is not the only one. The nurse should advise the client to maintain a healthy weight and to lose weight if they are overweight or obese, but not to focus on the scale alone.

Choice D reason: Getting regular physical activity is the most important instruction for a client with hypertension. Physical activity can lower blood pressure by strengthening the heart, improving blood circulation, reducing stress, and preventing or managing other risk factors, such as obesity, diabetes, and high cholesterol. The nurse should advise the client to engage in moderate aerobic exercise for at least 30 minutes a day, five days a week, and to consult their health care provider before starting any new exercise program.

Choice A reason: The nurse would include the question of whether the client ever uses oxygen, as this can be related to erythema. Erythema is a condition where the skin becomes red and inflamed due to increased blood flow or irritation. ¹ One possible cause of erythema is oxygen toxicity, which is a condition where the lungs and tissues are damaged by exposure to high levels of oxygen. ² The nurse would ask the client if they ever use oxygen, especially at high concentrations or for long periods of time, as this can increase the risk of oxygen toxicity and erythema.

Choice B reason: The nurse would not include the question of how many pillows the client sleeps on, as this is not related to erythema. The number of pillows the client sleeps on may indicate the presence of other conditions, such as sleep apnea, acid reflux, or heart failure, but not erythema. ³ The nurse would ask the client about their sleeping habits and preferences, but not specifically about the number of pillows they use.

Choice C reason: The nurse would not include the question of whether the client feels rested after sleeping, as this is not related to erythema. The feeling of restfulness after sleeping may indicate the quality and quantity of sleep the client gets, which can affect their overall health and well-being, but not erythema. The nurse would ask the client about their sleep patterns and problems, but not specifically about their feeling of restfulness.

Choice D reason: The nurse would not include the question of how far the client can walk before feeling short of breath, as this is not related to erythema. The distance the client can walk before feeling short of breath may indicate the level of physical activity and fitness the client has, which can affect their cardiovascular and respiratory health, but not erythema. The nurse would ask the client about their exercise habits and limitations, but not specifically about their walking distance.