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.

Determine the client’s food preferences.

Maintain a patent intravenous site.

Keep room temperature cool.

Answer and Explanation

The Correct Answer is C

Choice A reason: Teaching the client relaxation techniques is a helpful action that the nurse can implement, but it is not the most important one. Relaxation techniques, such as deep breathing, meditation, or guided imagery, can help the client cope with stress, anxiety, and agitation, which are common symptoms of Grave’s disease, a condition that causes hyperthyroidism and overactivity of the thyroid gland. However, relaxation techniques alone cannot address the client’s physical needs, such as hydration, nutrition, and electrolyte balance, which are more urgent and critical.

Choice B reason: Determining the client’s food preferences is a considerate action that the nurse can implement, but it is not the most important one. Food preferences, such as taste, texture, temperature, and variety, can affect the client’s appetite and willingness to eat, which are important factors for maintaining adequate nutrition and weight. However, food preferences may not be the main reason for the client’s refusal to eat, and they may not be enough to overcome the client’s metabolic demands, which are increased by Grave’s disease.

Choice C reason: Maintaining a patent intravenous site is the most important action that the nurse should implement, given the client’s situation. A patent intravenous site can allow the nurse to administer fluids, electrolytes, medications, and nutrients to the client, who is at risk of dehydration, malnutrition, and complications from Grave’s disease, such as thyroid storm, cardiac arrhythmias, and infection. The nurse should monitor the client’s vital signs, fluid intake and output, blood glucose, and thyroid function tests, and adjust the intravenous therapy accordingly.

Choice D reason: Keeping room temperature cool is a supportive action that the nurse can implement, but it is not the most important one. Room temperature can affect the client’s comfort and thermoregulation, which are impaired by Grave’s disease, which causes heat intolerance, sweating, and fever. However, room temperature alone cannot correct the underlying hormonal imbalance or the systemic effects of Grave’s disease, and it may not be sufficient to prevent the client from becoming restless and agitated.

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Correct Answer is C

Explanation

Choice A reason: Swabbing the throat for a rapid strep test is not a priority action that the nurse should implement, because it is not relevant to the client's current condition. A rapid strep test is a diagnostic tool that can detect the presence of Streptococcus bacteria in the throat, which can cause strep throat, a common bacterial infection. However, the client has already been diagnosed with strep throat and has been taking antibiotics for three days, so the test result may not be accurate or useful.

Choice B reason: Providing a mask for the client to wear is not a necessary action that the nurse should implement, because it is not related to the client's problem. A mask is a protective device that can prevent the transmission of respiratory infections, such as COVID-19, influenza, or tuberculosis, by blocking the droplets or aerosols that contain the pathogens. However, the client's symptoms are not caused by a respiratory infection, but by an allergic reaction to the antibiotics, which is not contagious.

Choice C reason: Instructing the client to stop taking the antibiotics is the most important action that the nurse should implement, because it can prevent further exposure to the allergen and reduce the severity of the reaction. The client's symptoms, such as rash, wheezing, and tachycardia, indicate that the client is having an allergic reaction to the antibiotics, which can be a serious and potentially life-threatening condition, especially if it progresses to anaphylaxis, a severe systemic reaction that can cause shock, airway obstruction, and organ failure. The nurse should instruct the client to stop taking the antibiotics immediately and notify the doctor.

Choice D reason: Applying a hypoallergenic cream to the rash is not a sufficient action that the nurse should implement, because it can only provide temporary relief and not address the underlying cause of the rash. A hypoallergenic cream is a topical product that can moisturize, soothe, and protect the skin, and it does not contain any ingredients that can cause allergic reactions. However, the rash is not caused by a skin irritant, but by a systemic reaction to the antibiotics, which requires more than a cream to treat.

A. Teach the client breathing exercises. B. Establish a regular bladder routine. C. Perform chest physiotherapy. D. Encourage use of incentive spirometer. E. Initiate passive range of motion exercises.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason: Teaching the client breathing exercises can help improve lung function, reduce mucus accumulation, and prevent atelectasis and pneumonia. Breathing exercises can include pursed-lip breathing, diaphragmatic breathing, and coughing techniques.

Choice B reason: Establishing a regular bladder routine is not directly related to pulmonary complications. However, it can help prevent urinary tract infections, bladder distension, and incontinence, which are common problems for clients with ALS.

Choice C reason: Performing chest physiotherapy can help mobilize secretions, improve ventilation, and prevent respiratory infections. Chest physiotherapy can include percussion, vibration, and postural drainage.

Choice D reason: Encouraging use of incentive spirometer can help increase lung expansion, improve oxygenation, and prevent alveolar collapse. Incentive spirometer is a device that measures the amount of air the client can inhale and exhale.

Choice E reason: Initiating passive range of motion exercises can help maintain joint mobility, prevent contractures, and improve circulation. Passive range of motion exercises are performed by the nurse or a caregiver who moves the client's limbs through their full range of motion.

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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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