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 D

Explanation

Choice A rationale: This is not relevant to the current condition of the patient and does not support a diagnosis of renal calculi.

Choice B rationale: This is a sign of upper gastrointestinal bleeding, which can have many causes such as peptic ulcer, gastritis or esophageal varices. It is not related to renal calculi or urinary tract problems.

Choice C rationale: Renal calculi usually causes pain which usually radiates anteriorly to the lower abdomen, groin, labia, testicles or the perineum depending on the location of the stone.

Choice D rationale: This is a sign of hematuria, which is blood in the urine caused by the passage of renal calculi (kidney stones) through the urinary tract. Hematuria can also cause the urine to appear dark or brown in color.

A. The skin under the appliance looks red briefly after removing the appliance. B. The stoma color is a deep red-purple. C. An ascending colostomy delivers liquid feces. D. The stoma extends 1/2 inch above the abdomen.

Correct Answer is B

Explanation

Choice A rationale: Redness briefly after removing the appliance might be common due to increased blood flow but does not necessarily indicate an issue.

Choice B rationale: A deep red-purple stoma color can suggest impaired blood supply to the stoma and requires immediate attention.

Choice C rationale: The consistency of output from the colostomy may vary based on the site and type of colostomy and might not necessarily be concerning.

Choice D rationale: The length of the stoma can vary and usually depends on the type of colostomy, and 1/2 inch above the abdomen is within an acceptable range.

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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?

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Correct Answer is D

Explanation

The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy?

Correct Answer is B

Explanation

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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?