Which intervention should be included in the plan of care for an infant with the nursing diagnosis of Excess Fluid Volume related to congestive heart failure?

The child should receive his regular dose of insulin even if he does not have an appetite. If the child is not eating as usual, he needs calories to prevent hypoglycemia. During periods of minor illness, the child with type 1 diabetes mellitus can be managed safely at home.

Choice A is wrong because giving the child half his regular morning dose of insulin can lead to hyperglycemia and ketoacidosis.

Choice C is wrong because giving the child plenty of unsweetened, clear liquids to prevent dehydration can also cause hypoglycemia.

Choice D is wrong because taking the child directly to the emergency department is not necessary unless the child has signs of severe dehydration, vomiting, abdominal

Verbalizing the importance of monitoring for medication side effects.

Graves’ disease is an autoimmune disorder that causes hyperthyroidism, which means the thyroid gland produces too much thyroid hormone. This can lead to symptoms such as weight loss, increased appetite, nervousness, irritability, insomnia, heat intolerance, and palpitations. The medication methimazole is used to treat Graves’ disease by blocking the synthesis of thyroid hormone. However, methimazole can also cause serious side effects such as liver damage, agranulocytosis (low white blood cell count), and allergic reactions.

Therefore, the priority nursing goal for a 14 year old diagnosed with Graves’ disease is to verbalize the importance of monitoring for medication side effects and reporting them to the health care provider.

Choice A is wrong because relieving constipation is not a priority goal for Graves’ disease. Constipation is more likely to occur in hypothyroidism, which is the opposite of hyperthyroidism.

Choice B is wrong because allowing the adolescent to make decisions about whether or not to take medication is not a priority goal for Graves’ disease. While it is important to respect the adolescent’s autonomy and involve them in their care plan, they also need to understand the risks and benefits of taking medication and the consequences of not taking it.

Choice D is wrong because developing alternative educational goals is not a priority goal for Graves’ disease. Graves’ disease can affect the academic performance of adolescents due to cognitive and emotional changes caused by hyperthyroidism.

However, this does not mean that they need to change their educational goals. They may need extra support and accommodations from their teachers and parents to cope with their condition and achieve their potential.