A nurse is developing a plan of care for a client with a new diagnosis of Graves' disease.
Which of the following interventions does the nurse include in the plan of care?

Keeping the room well-lit at all time

Encouraging frequent ambulation and exercise

Providing a high-calorie and high protein diet

Placing extra blankets over the client

Answer and Explanation

The Correct Answer is C

Choice A rationale: Clients with Graves' disease may have increased sensitivity to light due to ocular manifestations like photophobia, so keeping the room well-lit may can cause eye irritation.

Choice B rationale: Encouraging frequent ambulation and exercise may worsen the symptoms of hyperthyroidism, such as tachycardia, palpitations, and tremors.

Choice C rationale: This is because clients with Graves' disease have an increased

metabolic rate and may experience weight loss, muscle wasting, and fatigue. A high- calorie and high protein diet can help prevent these complications and provide adequate nutrition for the client.

Choice D rationale: Placing extra blankets over the client may increase the body temperature and cause heat intolerance, which is another common symptom of Graves' disease.

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Correct Answer is B

Explanation

Choice A rationale: The 42-yr-old patient with secondary amenorrhea may have menopause, pregnancy, or a hormonal disorder. This is less urgent compared to the 19- year old patient.

Choice B rationale: This patient may have toxic shock syndrome, which is a life- threatening complication of tampon use that can cause organ failure and shock. The nurse should assess the patient's vital signs, remove the tampon, and initiate fluid resuscitation and antibiotic therapy.

Choice C rationale: This patient may have an infection or a complication of the balloon thermotherapy, which is a procedure to destroy the endometrial lining of the uterus and is not an emergency compared to the 19 year old.

Choice D rationale: This patient may have a displacement or perforation of the IUD, which is a contraceptive device that releases progestin into the uterus. However, this is not urgent compared to the 19 year old.

A. urinary catheter obstruction B. shock C. hyponatremia D. urinary tract infection

Correct Answer is A

Explanation

Choice A rationale: The signs and symptoms of urinary catheter obstruction include hematuria with clots, bladder spasms, and a feeling of urinary urgency. The nurse should increase the rate of the continuous bladder irrigation to flush out the clots and relieve the obstruction. The nurse should also monitor the client's vital signs, fluid balance, and pain level. The other options are not consistent with the client's presentation.

Choice B rationale: Shock would cause hypotension, tachycardia, and decreased urine output.

Choice C rationale: Hyponatremia would cause confusion, weakness, and seizures.

Choice D rationale: Urinary tract infection would cause fever, chills, and foul-smelling urine.

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A nurse is developing a plan of care for a client with a new diagnosis of Graves' disease.
Which of the following interventions does the nurse include in the plan of care?