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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: This refers to postrenal AKI, which is caused by an obstruction in the urinary tract that prevents urine from leaving the body.
Choice B rationale: This refers to AKI in general and is not specific compared to choice D.
Choice C rationale: This refers to intrinsic AKI, which is caused by damage to the kidney tissue or cells from various causes, such as inflammation, infection, toxins, or ischemia.
Choice D rationale: This is correct because it is pre-renal AKI, a condition in which kidney blood flow may become significantly reduced, including cases where a significant amount of fluid has been lost. This situation suggests potential hypovolemia (low blood volume) due to the massive GI bleed, which can lead to reduced kidney blood flow and subsequent acute kidney injury.
Correct Answer is B
Explanation
Choice A rationale: Localization of pain refers to the ability of an individual to pinpoint the exact location of pain, which is different from the described response.
Choice B rationale: Decorticate posturing involves the arms flexing inward toward the body, which is consistent with the observed response to nail bed pressure.
Choice C rationale: Decerebrate posturing involves extension and outward rotation of the arms, which is different from the described response.
Choice D rationale: Flexion withdrawal typically involves pulling away from a painful stimulus, which differs from the specific response observed in the scenario.
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