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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Applying too much ointment can deter its effectiveness. Apply a thin layer to prevent maceration: While overuse of ointments may cause skin breakdown, this does not address the root issue. Athlete's foot is a fungal infection, and triple antibiotic ointments are ineffective against fungi regardless of the quantity applied.
B. Continue using the ointment for a full week, even after the symptoms disappear: Triple antibiotic ointment targets bacterial infections, not fungal ones like athlete's foot (tinea pedis). Continuing an ineffective treatment delays proper care and may worsen the condition due to persistent fungal growth.
C. Antibiotics take two weeks to become effective against infections such as athlete's foot: This is incorrect, as antibiotics do not treat fungal infections. Athlete's foot requires antifungal therapy, either topical or systemic depending on severity, and proper hygiene to promote resolution.
D. Stop using the ointment and encourage complete drying of feet and wearing clean socks: Fungi thrive in moist, warm environments. Discontinuing the inappropriate antibiotic ointment, promoting foot hygiene, and keeping the feet dry with clean, breathable socks directly addresses the fungal nature of the condition and supports healing.
Correct Answer is B
Explanation
A. Explain that weight loss will be reversed after the acute phase of the stroke has ended: This response minimizes the family’s concern and overlooks the current nutritional deficit. Waiting for the acute phase to pass without implementing strategies to support nutritional intake can result in malnutrition and delayed recovery.
B. Demonstrate the use of visual scanning during meals to the client and family: Visual perception deficits, such as unilateral neglect, are common after a CVA and may cause the client to ignore food on one side of the tray. Teaching visual scanning techniques helps the client become aware of the neglected side and promotes full food intake, directly addressing the nutritional concern.
C. Suggest that the family bring foods from home that the client enjoys eating: While bringing familiar foods may increase appetite, it does not address the underlying issue of impaired visual perception. Even with preferred foods, the client may still miss food on the affected side, leading to inadequate intake.
D. Encourage the family to offer to feed the client when she does not eat her entire meal: Feeding assistance should only be considered when the client is unable to feed herself. Promoting independence through visual scanning techniques enhances functional recovery and dignity, while dependency can hinder rehabilitation and motivation.
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