An adult woman with Grave's disease is admitted with severe dehydration and malnutrition. She is currently restless and refusing to eat. Which action is most important for the nurse to implement?

Teach the client relaxation techniques.

Maintain a patent intravenous site.

Keep room temperature cool.

Determine the client's food preferences.

Answer and Explanation

The Correct Answer is B

A. Teach the client relaxation techniques: While stress reduction can help manage hypermetabolic symptoms associated with Grave’s disease, it does not address the client’s current acute condition. Restlessness and refusal to eat signal an urgent need to stabilize fluid and nutritional deficits before implementing supportive measures like relaxation techniques.

B. Maintain a patent intravenous site: Severe dehydration and malnutrition compromise cardiovascular stability and metabolic function in Grave’s disease, which is already associated with a hypermetabolic state. Ensuring IV access is crucial for administering fluids, electrolytes, and possibly medications to prevent complications such as thyroid storm or cardiac arrhythmias.

C. Keep room temperature cool: Although clients with hyperthyroidism often experience heat intolerance, adjusting the room temperature alone does not address the immediate risks posed by severe dehydration and malnutrition. Environmental comfort is secondary to maintaining physiologic stability through hydration and nutrition support.

D. Determine the client's food preferences: Identifying food preferences is appropriate for long-term nutritional support, but it is not the priority when a client is refusing food and showing signs of serious metabolic derangement. Parenteral or enteral nutrition may be needed first to stabilize the condition.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Encourage the client to use hard candy frequently to help relieve thirst: Clients with SIADH are usually on fluid restrictions to prevent further dilutional hyponatremia. Using non-liquid measures like hard candy, ice chips, or gum can help reduce the discomfort of persistent thirst without compromising fluid balance, making this a safe and supportive intervention.

B. Provide the client with additional oral fluids of her preference: Increasing fluid intake directly contradicts the management of SIADH, where excess antidiuretic hormone leads to water retention and hyponatremia. Additional fluids can exacerbate electrolyte imbalances and worsen neurological symptoms.

C. Measure the client's capillary glucose reading at regular intervals: While glucose monitoring may be necessary in clients with diabetes or altered mental status, thirst in SIADH is not related to hyperglycemia. This action would not address the underlying issue or contribute to symptom relief.

D. Withhold the next diuretic dose until contacting the healthcare provider: Diuretics may be used in SIADH to promote free water excretion. Withholding them without a specific clinical reason, such as hypotension or dehydration, may worsen fluid overload and hyponatremia.

A. The client's hemoglobin A1C will be less than 7% in 3 months. B. The nurse will encourage the client to walk thirty minutes every day. C. The client's blood pressure readings will be less than 160/90 mm Hg. D. The nurse will demonstrate the procedure for accurate eye care.

Correct Answer is A

Explanation

A. The client's hemoglobin A1C will be less than 7% in 3 months: This outcome is measurable, time-bound, and directly related to diabetes management. A hemoglobin A1C below 7% reflects good long-term glycemic control, which is essential in preventing or slowing complications like diabetic retinopathy, especially when blurred vision is already present.

B. The nurse will encourage the client to walk thirty minutes every day: While exercise is an important component of diabetes management and overall health, this is an intervention, not a client-centered outcome. An outcome would focus on the client's behavior or physiological response to the intervention (e.g., "The client will walk for thirty minutes at least five days a week").

C. The client's blood pressure readings will be less than 160/90 mm Hg: This target is too high for a client with diabetes. The recommended blood pressure goal in diabetic patients is typically under 130/80 mm Hg to reduce cardiovascular and renal complications. Therefore, this is not an ideal outcome.

D. The nurse will demonstrate the procedure for accurate eye care: Like option B, this describes a nursing intervention, not a measurable client outcome. Additionally, managing blurred vision in diabetes focuses more on glycemic control and ophthalmologic monitoring rather than routine eye care procedures.

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An adult woman with Grave's disease is admitted with severe dehydration and malnutrition. She is currently restless and refusing to eat. Which action is most important for the nurse to implement?

Nursing Test Bank

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Explanation

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