A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the health care provider?

Choice A reason: Teaching the client relaxation techniques is a helpful action that the nurse can implement, but it is not the most important one. Relaxation techniques, such as deep breathing, meditation, or guided imagery, can help the client cope with stress, anxiety, and agitation, which are common symptoms of Grave’s disease, a condition that causes hyperthyroidism and overactivity of the thyroid gland. However, relaxation techniques alone cannot address the client’s physical needs, such as hydration, nutrition, and electrolyte balance, which are more urgent and critical.

Choice B reason: Determining the client’s food preferences is a considerate action that the nurse can implement, but it is not the most important one. Food preferences, such as taste, texture, temperature, and variety, can affect the client’s appetite and willingness to eat, which are important factors for maintaining adequate nutrition and weight. However, food preferences may not be the main reason for the client’s refusal to eat, and they may not be enough to overcome the client’s metabolic demands, which are increased by Grave’s disease.

Choice C reason: Maintaining a patent intravenous site is the most important action that the nurse should implement, given the client’s situation. A patent intravenous site can allow the nurse to administer fluids, electrolytes, medications, and nutrients to the client, who is at risk of dehydration, malnutrition, and complications from Grave’s disease, such as thyroid storm, cardiac arrhythmias, and infection. The nurse should monitor the client’s vital signs, fluid intake and output, blood glucose, and thyroid function tests, and adjust the intravenous therapy accordingly.

Choice D reason: Keeping room temperature cool is a supportive action that the nurse can implement, but it is not the most important one. Room temperature can affect the client’s comfort and thermoregulation, which are impaired by Grave’s disease, which causes heat intolerance, sweating, and fever. However, room temperature alone cannot correct the underlying hormonal imbalance or the systemic effects of Grave’s disease, and it may not be sufficient to prevent the client from becoming restless and agitated.

Choice A reason: Obtaining a prostate-specific antigen blood level test is not a way to reduce risk factors for BPH, but a way to screen for prostate cancer, which is a different condition. Prostate-specific antigen (PSA) is a protein produced by the prostate gland, and its level may be elevated in men with prostate cancer or other prostate problems, such as BPH or prostatitis. However, PSA testing is not recommended for all men, and it has some limitations and risks. The nurse should discuss the benefits and harms of PSA testing with the client and help him make an informed decision.

Choice B reason: Taking vitamin supplements is not a proven way to reduce risk factors for BPH, and it may have some adverse effects, such as interactions with medications or increased bleeding. There is no clear evidence that any specific vitamin or mineral can prevent or treat BPH, and some studies have suggested that high doses of certain vitamins, such as vitamin E or folic acid, may increase the risk of prostate cancer. The nurse should advise the client to eat a balanced diet that includes fruits, vegetables, whole grains, and lean proteins, and to consult a doctor before taking any supplements.

Choice C reason: Increasing physical activity is a beneficial way to reduce risk factors for BPH, as well as to improve overall health and well-being. Physical activity can help maintain a healthy weight, lower blood pressure, reduce inflammation, and enhance blood flow to the pelvic area, which may prevent or delay the development of BPH. The nurse should encourage the client to engage in moderate-intensity aerobic exercise, such as brisk walking, cycling, or swimming, for at least 150 minutes per week, and to include some strength training and flexibility exercises as well.

Choice D reason: Consuming a high protein diet is not a helpful way to reduce risk factors for BPH, and it may have some negative effects, such as increasing the risk of kidney stones, gout, or osteoporosis. A high protein diet may also increase the intake of saturated fat, cholesterol, and sodium, which can raise the risk of cardiovascular disease and hypertension, which are also risk factors for BPH. The nurse should advise the client to limit the intake of animal protein, such as red meat, poultry, eggs, and dairy products, and to choose plant-based protein sources, such as beans, nuts, seeds, and soy products, more often.