The nurse is caring for a client admitted to the unit for possible hyperthyroidism. The client describes weakness, nervousness, a racing heartbeat, and recent weight loss of 15 pounds (6.8 kg). Which action should the nurse implement first?

Pace the client's care to provide periods of rest.

Make arrangements for radioactive iodine therapy.

Administer beta-adrenergic blocking agent.

Monitor the client's vital signs frequently.

Answer and Explanation

The Correct Answer is D

Choice A reason: Pacing the client's care to provide periods of rest is important for managing fatigue and preventing overexertion. However, it is not the first action the nurse should take in this situation. Monitoring vital signs is crucial to assess the client's current condition and detect any immediate complications.

Choice B reason: Making arrangements for radioactive iodine therapy is a treatment option for hyperthyroidism. However, this is not the first action the nurse should take. The nurse needs to assess the client's condition and stabilize any immediate issues before considering long-term treatment options.

Choice C reason: Administering a beta-adrenergic blocking agent can help manage symptoms such as a racing heartbeat and nervousness. While this may be part of the treatment plan, it is not the first action the nurse should take. Monitoring vital signs is essential to determine the appropriate interventions.

Choice D reason: Monitoring the client's vital signs frequently is the first action the nurse should take. This helps assess the client's current condition, detect any immediate complications, and guide further interventions. It is crucial to ensure the client's stability before implementing other care measures.

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Correct Answer is D

Explanation

Choice A reason: While it is important to communicate the risks of not using the incentive spirometer, this statement is overly alarming and may cause unnecessary anxiety for the client. It is better to focus on positive outcomes and preventive measures.

Choice B reason: This statement informs the client that incentive spirometry is routine and will be demonstrated postoperatively, but it does not provide specific details about its benefits or importance.

Choice C reason: This statement explains the use of the incentive spirometer on the first postoperative day, but it does not address the overall goal of preventing complications through lung exercises.

Choice D reason: This statement effectively explains the purpose and benefits of deep breathing exercises, including using the incentive spirometer. It emphasizes the importance of maintaining lung capacity and strengthening respiratory muscles to prevent complications, providing a clear rationale for the intervention.

A. Minimize intake of spicy foods. B. Begin a smoking cessation program. C. Avoid wearing tight-fitting clothes. D. Remain upright following meals.

Correct Answer is D

Explanation

Choice A reason: Minimizing the intake of spicy foods can help reduce GERD symptoms, but it is not the most critical instruction for preventing reflux immediately after eating.

Choice B reason: Beginning a smoking cessation program is important for overall health and can help reduce GERD symptoms over time, but it is not the immediate priority for preventing reflux.

Choice C reason: Avoiding tight-fitting clothes can help reduce pressure on the abdomen and lessen reflux symptoms, but it is not the most urgent instruction to emphasize at discharge.

Choice D reason: Remaining upright following meals is crucial for preventing reflux. Lying down immediately after eating can cause stomach contents to flow back into the oesophagus, exacerbating GERD symptoms. This instruction is key to managing the condition effectively.

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The nurse is caring for a client admitted to the unit for possible hyperthyroidism. The client describes weakness, nervousness, a racing heartbeat, and recent weight loss of 15 pounds (6.8 kg). Which action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching the client about incentive spirometry in the preoperative unit. Which statement regarding incentive spirometry should the nurse include with preoperative teaching?

Correct Answer is D

Explanation

The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?

Correct Answer is D

Explanation

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