During the nursing assessment of a patient with Graves' disease. The nurse notes a bounding, rapid pulse and systolic hypertension. Based on these assessment data, which question is important for the nurse to ask the patient?
“Do you ever have any chest pain?'
“Have you noticed any recent decrease in your appetite?”
“Do you have any problem with frequent constipation?”
The Correct Answer is A
The patient's bounding, rapid pulse and systolic hypertension may indicate cardiovascular complications associated with Graves' disease, such as tachycardia, atrial fibrillation, or congestive heart failure, which can cause chest pain. It is important for the nurse to assess for any symptoms of cardiovascular distress and report any abnormal findings to the healthcare provider for prompt intervention. Questions about appetite and constipation may be relevant to the patient's overall health status, but they are not the most important concern in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Although increasing fluid intake and fiber intake are important interventions for preventing constipation, it is important to first assess the patient's current situation and risk factors for constipation. Additionally, while a daily bowel movement is not necessary for everyone, it is important to understand the patient's usual bowel habits and whether or not their current regimen is effective for them. Therefore, the nurse should perform a focused nursing assessment to identify the patient's risk factors for constipation and evaluate their current bowel regimen before providing specific interventions or recommendations.
Correct Answer is C
Explanation
The patient with primary hyperparathyroidism has high levels of calcium in the blood (hypercalcemia) which can lead to symptoms such as kidney stones, bone pain, and weakness. High urine calcium levels may also be present due to the increased calcium in the blood.
One important intervention for managing hypercalcemia is to encourage fluid intake to promote increased urine output and prevent the formation of kidney stones. Therefore, the nurse should encourage the patient to drink at least 4000 ml of fluids per day.
Seizure precautions (a), range-of-motion exercises (b), and monitoring for positive Chvostek’s or Trousseaus sign (d) are not directly related to managing hypercalcemia and are not necessary in this case.
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