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?

Keep room temperature cool.

Determine the client's food preferences.

Maintain a patent intravenous site.

Teach the client relaxation techniques.

Answer and Explanation

The Correct Answer is C

Choice A reason: Keeping the room temperature cool may help with comfort but is not the immediate priority.

Choice B reason: Determining the client's food preferences is important for nutritional management but is not the first action to take.

Choice C reason:

The correct answer is c) because maintaining a patent intravenous site is crucial for administering fluids and medications to address severe dehydration and malnutrition.

Choice D reason: Teaching relaxation techniques can help with restlessness but is not the most immediate concern.

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Correct Answer is C

Explanation

Choice A reason: Increasing the frequency of BP assessments is important to monitor the client's condition, but it does not address the potential cause of the drop in blood pressure.

Choice B reason: Encouraging the client to breathe deeply is useful for overall respiratory function but does not address the specific issue of the dropping blood pressure.

Choice C reason:

The correct answer is c) because checking the abdominal surgical dressing can help identify if there is postoperative bleeding or other complications at the surgical site, which could be causing the drop in blood pressure.

Choice D reason: Reviewing the client's baseline BP trends provides useful information but does not address the immediate potential cause of the blood pressure change.

A. A 70-year-old fair-skinned client who works as a secretary. B. A 65-year-old fair-skinned client who is a construction worker. C. A 25-year-old dark-skinned client whose mother had skin cancer. D. A 16-year-old dark-skinned client who tans in tanning beds once a week.

Correct Answer is B

Explanation

Choice A reason: While being fair-skinned and older increases risk, exposure to UV radiation is a significant factor.

Choice B reason:

The correct answer is b) because a fair-skinned client who works outdoors (construction worker) has higher exposure to UV radiation, increasing the risk of skin cancer.

Choice C reason: Having a family history of skin cancer is a risk factor, but dark-skinned individuals have lower risk compared to fair-skinned individuals with high UV exposure.

Choice D reason: Tanning bed use increases risk, but fair-skinned individuals with prolonged UV exposure have a higher overall risk.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

One hour after major abdominal surgery, a client in the postanesthesia care unit (PACU) has a blood pressure (BP) of 136/80 mm Hg. Fifteen minutes later, it is 114/72 mm Hg. Which action should the nurse take first?

Correct Answer is C

Explanation

Which client has the highest risk for developing skin cancer?

Correct Answer is B

Explanation

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