When palpating the child's cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm.
The best explanation for this is.

The correct answer is choice c. Verbalizing the importance of monitoring for medication side effects.

Choice A rationale:

Relieving constipation is not typically a priority for patients with Graves’ disease, as constipation is not a common symptom of this condition.

Choice B rationale:

While involving adolescents in their care decisions is important, allowing them to decide whether or not to take medication is not appropriate. Adherence to medication is crucial for managing Graves’ disease.

Choice C rationale:

Verbalizing the importance of monitoring for medication side effects is essential. Graves’ disease treatment often involves medications that can have significant side effects, and monitoring these is critical for effective management and patient safety.

Choice D rationale:

Developing alternative educational goals is not directly related to the immediate management of Graves’ disease. While educational support is important, it is not the primary nursing goal in this context.

Choice A rationale:

A stat magnesium sulfate level (Choice A) is unnecessary in this situation. The symptoms described - increased temperature, pulse rate, and blood pressure, along with absent deep tendon reflexes - indicate magnesium sulfate toxicity. Discontinuing the infusion and managing the symptoms take precedence over checking the magnesium sulfate level.

Choice B rationale:

Administering oxygen (Choice B) is important for maintaining the patient's oxygenation levels, but it does not address the magnesium sulfate toxicity. The primary intervention should be to discontinue the infusion and manage the symptoms.

Choice C rationale:

Discontinuing the magnesium sulfate infusion (Choice C) is the correct action in this situation. The symptoms, including absent deep tendon reflexes and the patient's complaint of thirst and warmth, indicate magnesium sulfate toxicity. Stopping the infusion is crucial to prevent further complications.

Choice D rationale:

Hydralazine (Choice D) is an antihypertensive medication and is not the appropriate intervention for magnesium sulfate toxicity. Managing magnesium sulfate toxicity involves discontinuing the infusion and providing supportive care.