An adult woman with Grave’s disease is admitted with severe dehydration and malnutrition. She is currently restless and refusing to eat. Which action is most important for the nurse to implement?

Teach the client relaxation techniques.

Determine the client’s food preferences.

Maintain a patent intravenous site.

Keep room temperature cool.

Answer and Explanation

The Correct Answer is C

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.

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Correct Answer is B

Explanation

Choice A reason: White blood cell count and pulse rate are not the most important information about the client that the nurse should tell the healthcare provider, because they are not directly related to the AAA or the low back pain. White blood cell count is a measure of the immune system activity, and it may be elevated in cases of infection or inflammation, but it is not specific to AAA. Pulse rate is a measure of the heart rate, and it may be increased in cases of anxiety, pain, or shock, but it is not indicative of AAA.

Choice B reason: Hematocrit and blood pressure are the most important information about the client that the nurse should tell the healthcare provider, because they are directly related to the AAA and the low back pain. Hematocrit is a measure of the percentage of red blood cells in the blood, and it may be decreased in cases of bleeding or anemia, which can occur if the AAA ruptures or leaks. Blood pressure is a measure of the force of the blood against the walls of the arteries, and it may be increased in cases of hypertension or stress, which can worsen the AAA or cause it to rupture. The nurse should monitor the client's hematocrit and blood pressure closely and report any changes to the healthcare provider.

Choice C reason: Calcium level and skin condition are not the most important information about the client that the nurse should tell the healthcare provider, because they are not directly related to the AAA or the low back pain. Calcium level is a measure of the amount of calcium in the blood, and it may be abnormal in cases of bone disorders, kidney disorders, or parathyroid disorders, but it is not relevant to AAA. Skin condition is a general term that can describe the appearance, texture, color, or temperature of the skin, and it may be altered in cases of infection, allergy, or injury, but it is not specific to AAA.

Choice D reason: Serum amylase and level of consciousness are not the most important information about the client that the nurse should tell the healthcare provider, because they are not directly related to the AAA or the low back pain. Serum amylase is a measure of the amount of amylase, an enzyme that digests starch, in the blood, and it may be elevated in cases of pancreatitis, gallstones, or intestinal obstruction, but it is not associated with AAA. Level of consciousness is a measure of the client's mental status, alertness, and responsiveness, and it may be impaired in cases of brain injury, stroke, or coma, but it is not indicative of AAA.

A. Use incentive spirometer. B. Monitor urinary stream for decrease in output. C. Report when hematuria becomes pink tinged. D. Restrict physical activities.

Correct Answer is B

Explanation

Choice A reason: Using incentive spirometer is not a relevant instruction for a client with BPH who underwent TUNA. Incentive spirometer is a device that helps improve lung function and prevent respiratory complications after surgery or prolonged bed rest. TUNA is a minimally invasive procedure that uses radiofrequency energy to shrink the prostate tissue and relieve the urinary obstruction. TUNA does not affect the respiratory system or require general anesthesia.

Choice B reason: Monitoring urinary stream for decrease in output is an important instruction for a client with BPH who underwent TUNA. Urinary output can reflect the kidney function and the effectiveness of the procedure. A decrease in urinary output can indicate urinary retention, infection, or bleeding, which are potential complications of TUNA. The client should report any changes in the urinary stream, such as difficulty, pain, frequency, urgency, or hesitancy, to the health care provider.

Choice C reason: Reporting when hematuria becomes pink tinged is not a necessary instruction for a client with BPH who underwent TUNA. Hematuria is the presence of blood in the urine, which is a common and expected finding after TUNA. Hematuria usually resolves within a few days and does not require intervention, unless it is excessive or persistent. The client should drink plenty of fluids to flush out the blood and prevent clot formation. The client should report any signs of infection, such as fever, chills, or foul-smelling urine, to the health care provider.

Choice D reason: Restricting physical activities is a correct instruction for a client with BPH who underwent TUNA. Physical activities can increase the blood pressure and the risk of bleeding or injury to the prostate. The client should avoid strenuous activities, such as lifting, running, or biking, for at least two weeks after the procedure. The client should also avoid sexual intercourse, driving, or sitting for long periods until the symptoms subside. The client should follow the health care provider's advice on when to resume normal activities.

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An adult woman with Grave’s disease is admitted with severe dehydration and malnutrition. She is currently restless and refusing to eat. Which action is most important for the nurse to implement?

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