A client who fractured the right femur from a fall at home is placed in skeletal traction while awaiting surgery. When the client tells the nurse the need to urinate, which intervention should the nurse implement?

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: Joint pain is a common symptom of SLE, which is an autoimmune disease that causes inflammation and damage to various organs and tissues. Joint pain can be managed with anti-inflammatory drugs, analgesics, and corticosteroids. Joint pain is not a life-threatening finding that requires immediate attention from the health care provider.

Choice B reason: Hematuria is the presence of blood in the urine, which can indicate kidney damage or failure. Kidney involvement is one of the most serious complications of SLE, which can lead to end-stage renal disease and require dialysis or transplantation. Hematuria is a critical finding that requires prompt intervention and treatment from the health care provider.

Choice C reason: Low grade fever is another common symptom of SLE, which can be caused by infection, inflammation, or medication side effects. Low grade fever can be treated with antipyretics, fluids, and antibiotics if needed. Low grade fever is not a life-threatening finding that requires immediate attention from the health care provider.

Choice D reason: Muscle atrophy is the loss of muscle mass and strength, which can occur due to inactivity, malnutrition, or steroid use. Muscle atrophy can be prevented or reversed with exercise, nutrition, and physiotherapy. Muscle atrophy is not a life-threatening finding that requires immediate attention from the health care provider.