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 C

Explanation

Choice A reason: Swabbing the throat for a rapid strep test is not a priority action that the nurse should implement, because it is not relevant to the client's current condition. A rapid strep test is a diagnostic tool that can detect the presence of Streptococcus bacteria in the throat, which can cause strep throat, a common bacterial infection. However, the client has already been diagnosed with strep throat and has been taking antibiotics for three days, so the test result may not be accurate or useful.

Choice B reason: Providing a mask for the client to wear is not a necessary action that the nurse should implement, because it is not related to the client's problem. A mask is a protective device that can prevent the transmission of respiratory infections, such as COVID-19, influenza, or tuberculosis, by blocking the droplets or aerosols that contain the pathogens. However, the client's symptoms are not caused by a respiratory infection, but by an allergic reaction to the antibiotics, which is not contagious.

Choice C reason: Instructing the client to stop taking the antibiotics is the most important action that the nurse should implement, because it can prevent further exposure to the allergen and reduce the severity of the reaction. The client's symptoms, such as rash, wheezing, and tachycardia, indicate that the client is having an allergic reaction to the antibiotics, which can be a serious and potentially life-threatening condition, especially if it progresses to anaphylaxis, a severe systemic reaction that can cause shock, airway obstruction, and organ failure. The nurse should instruct the client to stop taking the antibiotics immediately and notify the doctor.

Choice D reason: Applying a hypoallergenic cream to the rash is not a sufficient action that the nurse should implement, because it can only provide temporary relief and not address the underlying cause of the rash. A hypoallergenic cream is a topical product that can moisturize, soothe, and protect the skin, and it does not contain any ingredients that can cause allergic reactions. However, the rash is not caused by a skin irritant, but by a systemic reaction to the antibiotics, which requires more than a cream to treat.

A. Reorient to day and time frequently. B. Apply soft wrist restraints bilaterally. C. Administer a PRN dose of lorazepam. D. Turn the television on for distraction. E. Present a calm, supportive demeanor.

Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Reorienting to day and time frequently is a nursing intervention that the nurse should implement, because it can help the client to reduce confusion, anxiety, and disorientation, which may contribute to the auditory hallucinations. The nurse should use simple and clear language, speak slowly and calmly, and provide cues and reminders, such as a clock, a calendar, or a picture, to help the client to orient to reality.

Choice B reason: Applying soft wrist restraints bilaterally is not a nursing intervention that the nurse should implement, unless it is absolutely necessary and ordered by the doctor. Restraints can increase the client's agitation, anxiety, and fear, and they can also cause physical and psychological harm, such as skin breakdown, nerve damage, or loss of dignity. The nurse should use restraints only as a last resort, after trying other less restrictive alternatives, such as verbal de-escalation, distraction, or medication.

Choice C reason: Administering a PRN dose of lorazepam is a nursing intervention that the nurse should implement, if it is prescribed by the doctor and indicated by the client's condition. Lorazepam is a benzodiazepine that can help the client to relax, reduce anxiety, and sedate the central nervous system, which may alleviate the auditory hallucinations. The nurse should monitor the client's vital signs, level of consciousness, and respiratory status, and report any adverse effects, such as hypotension, bradycardia, or respiratory depression.

Choice D reason: Turning the television on for distraction is not a nursing intervention that the nurse should implement, because it can worsen the client's auditory hallucinations, confusion, and agitation. The television can provide too much stimulation, noise, and information, which can overload the client's sensory perception and interfere with their ability to distinguish reality from hallucination. The nurse should provide a quiet and calm environment, and limit the sources of auditory input.

Choice E reason: Presenting a calm, supportive demeanor is a nursing intervention that the nurse should implement, because it can help the client to feel safe, comfortable, and respected, and to establish a trusting relationship with the nurse. The nurse should show empathy, compassion, and patience, and avoid arguing, criticizing, or dismissing the client's hallucinations. The nurse should acknowledge the client's feelings, validate their distress, and reassure them that they are not alone.

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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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Explanation

Correct Answer is ["A","C","E"]

Explanation

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