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 A

Explanation

Choice A reason: Administering analgesics on a fixed and continuous schedule is the most important intervention that the nurse should include in this client’s plan of care, because it can provide consistent and adequate pain relief for the client with metastatic cancer, who is likely to have chronic and severe pain. The nurse should follow the principles of cancer pain management, such as using the WHO analgesic ladder, titrating the dose according to the pain intensity, and using a multimodal approach that combines opioids, non-opioids, and adjuvants.

Choice B reason: Frequently evaluating the client’s pain is an important intervention that the nurse should include in this client’s plan of care, but it is not the most important one. Evaluating the client’s pain can help the nurse to assess the effectiveness of the analgesics, identify the characteristics and causes of the pain, and adjust the pain management plan accordingly. However, evaluating the pain alone is not enough to provide pain relief, and the nurse should also implement the appropriate interventions based on the evaluation.

Choice C reason: Replacing transdermal analgesic patches every 72 hours is not a relevant intervention that the nurse should include in this client’s plan of care, because it is not applicable to the client’s situation. Transdermal analgesic patches are a form of opioid delivery that can provide long-lasting pain relief, but they are not suitable for acute or breakthrough pain, and they have a delayed onset of action. The client in this scenario is receiving IV analgesics, which have a faster onset and shorter duration of action, and are more appropriate for acute or breakthrough pain.

Choice D reason: Monitoring the client for break-through pain is an important intervention that the nurse should include in this client’s plan of care, but it is not the most important one. Break-through pain is a sudden and transient increase in pain that occurs despite the use of regular analgesics, and it can be caused by various factors, such as movement, infection, or tumor progression. The nurse should monitor the client for break-through pain and administer rescue doses of analgesics as needed. However, monitoring the client for break-through pain is not enough to prevent or treat the pain, and the nurse should also administer analgesics on a fixed and continuous schedule to maintain a steady level of pain relief.

A. Joint pain. B. Hematuria. C. Low grade fever. D. Muscle atrophy.

Correct Answer is B

Explanation

Choice A reason: Joint pain is a common symptom of SLE, which is an autoimmune disease that causes inflammation and damage to various organs and tissues. Joint pain can be managed with anti-inflammatory drugs, analgesics, and corticosteroids. Joint pain is not a life-threatening finding that requires immediate attention from the health care provider.

Choice B reason: Hematuria is the presence of blood in the urine, which can indicate kidney damage or failure. Kidney involvement is one of the most serious complications of SLE, which can lead to end-stage renal disease and require dialysis or transplantation. Hematuria is a critical finding that requires prompt intervention and treatment from the health care provider.

Choice C reason: Low grade fever is another common symptom of SLE, which can be caused by infection, inflammation, or medication side effects. Low grade fever can be treated with antipyretics, fluids, and antibiotics if needed. Low grade fever is not a life-threatening finding that requires immediate attention from the health care provider.

Choice D reason: Muscle atrophy is the loss of muscle mass and strength, which can occur due to inactivity, malnutrition, or steroid use. Muscle atrophy can be prevented or reversed with exercise, nutrition, and physiotherapy. Muscle atrophy is not a life-threatening finding that requires immediate attention from the health care provider.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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