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 A
Explanation
Choice A reason:
The correct answer is a) because a mask-like face in Parkinson's disease can affect the ability to chew and swallow, increasing the risk of aspiration and nutritional deficiencies.
Choice B reason: Assessing speech patterns is important but secondary to ensuring the client can chew and swallow safely.
Choice C reason: Noting the frequency of drooling can indicate difficulties with swallowing, but determining the ability to chew and swallow is more critical.
Choice D reason: Observing the appearance of the oral mucosa is important for overall oral health but does not address the immediate risk of aspiration and nutritional concerns.
Correct Answer is C
Explanation
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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