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?
Keep room temperature cool.
Determine the client's food preferences.
Maintain a patent intravenous site.
Teach the client relaxation techniques.
The Correct Answer is C
Choice A reason: Keeping the room temperature cool may help with comfort but is not the immediate priority.
Choice B reason: Determining the client's food preferences is important for nutritional management but is not the first action to take.
Choice C reason:
The correct answer is c) because maintaining a patent intravenous site is crucial for administering fluids and medications to address severe dehydration and malnutrition.
Choice D reason: Teaching relaxation techniques can help with restlessness but is not the most immediate concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: High-potassium foods should be monitored but are not the primary concern for AGN.
Choice B reason: Protein intake should be managed but not necessarily increased.
Choice C reason: Avoiding high-carbohydrate foods is not specific to AGN management.
Choice D reason:
The correct answer is d) because restricting sodium intake helps manage fluid retention and hypertension, which are common issues in AGN.
Correct Answer is B
Explanation
Choice A reason: Deep partial-thickness burns are characterized by blisters and significant pain.
Choice B reason:
The correct answer is b) because full-thickness burns involve all layers of the skin and can extend into underlying tissues. They often appear brown or yellow and are usually painless due to nerve damage.
Choice C reason: Superficial partial-thickness burns affect the epidermis and part of the dermis, causing pain and redness.
Choice D reason: Deep full-thickness burns are also a possible answer, but full-thickness better describes the extent and characteristics given.
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