A nurse is caring for a client who is receiving one unit of packed red blood cells (RBCs) due to intraoperative blood loss.
The client reports chills and back pain, and their blood pressure is 80/64 mm Hg. What should be the nurse’s first action?

Choice A rationale
This statement is not entirely accurate. Crohn’s disease does not resemble a second-degree burn. It is an inflammatory bowel disease that can affect any part of the gastrointestinal tract.
Choice B rationale
While this statement is technically correct, it uses medical jargon that may be difficult for a patient to understand. Crohn’s disease is indeed characterized by transmural granulomatous inflammation, meaning it affects the entire wall of the gastrointestinal tract. However, this description may not be easily understood by a patient without a medical background.
Choice C rationale
This statement is partially correct but not entirely accurate. Crohn’s disease can cause inflammation in the mucosa and sub-mucosa of the colon and rectal linings, but it is not limited to these areas. It can affect any part of the gastrointestinal tract from the mouth to the anus.
Choice D rationale
This is the most simplistic and non-medical description of the disorder. Crohn’s disease can indeed give the appearance of a “patchwork quilt” in the gastrointestinal tract, with some areas

clear and others inflamed or ulcerated. This description provides a visual analogy that may be easier for a patient to understand.

Choice A rationale
Providing a quiet, low-stimulus environment is one of the key interventions for a patient with hyperthyroidism who is at risk of a thyroid crisis. Hyperthyroidism is characterized by an overproduction of thyroid hormones, which can accelerate the body’s metabolism causing symptoms such as rapid heart rate, increased appetite, increased perspiration, fatigue, menstrual irregularity, and restlessness. A thyroid crisis, also known as a thyroid storm, is a severe, life-threatening condition characterized by extreme symptoms of hyperthyroidism. A quiet, low-stimulus environment can help reduce anxiety and agitation, which can exacerbate symptoms and potentially trigger a thyroid crisis.
Choice B rationale
Keeping the patient NPO (nothing by mouth) is not typically necessary in the management of hyperthyroidism unless the patient is preparing for a procedure such as thyroid surgery. In

fact, because of the increased metabolic rate in hyperthyroidism, patients often have an increased appetite and may require additional caloric intake.
Choice C rationale
Administering aspirin for any sign of hyperthermia is not recommended in hyperthyroidism. Aspirin can actually increase the level of free thyroid hormones in the blood by displacing them from their binding proteins, potentially worsening the hyperthyroid state.
Choice D rationale
While it is important to observe patients with hyperthyroidism for signs of various complications, hypocalcemia is not typically associated with hyperthyroidism. Hypocalcemia, or low calcium levels in the blood, is more commonly associated with hypoparathyroidism or vitamin D deficiency.