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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Bile-stained emesis indicates an obstruction, but it is not as immediately critical as a distended, hard, and rigid abdomen.

Choice B reason: Clay-colored stool is a sign of bile duct obstruction but is not as urgent as the abdomen findings.

Choice C reason:

The correct answer is c) because a distended, hard, and rigid abdomen suggests peritonitis or a perforated organ, which requires immediate medical intervention.

Choice D reason: Radiating, sharp pain in the right shoulder is common in gallbladder issues but is not as immediately life-threatening as a distended, hard, and rigid abdomen.

A. Altered tissue perfusion. B. Sleep pattern disturbance. C. Risk for injury. D. Risk of infection.

Correct Answer is C

Explanation

Choice A reason: Altered tissue perfusion is important but not the primary concern in osteomalacia.

Choice B reason: Sleep pattern disturbance may occur but is not the highest priority.

Choice C reason:

The correct answer is c) because clients with osteomalacia have weakened bones and are at high risk for fractures, making injury prevention the highest priority.

Choice D reason: Risk of infection is important but not the primary concern in osteomalacia.

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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

A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider?

Correct Answer is C

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Which nursing problem has the highest priority when planning care for a client with osteomalacia?

Correct Answer is C

Explanation

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