What is the priority nursing goal for a 14-year-old diagnosed with Graves’ disease?
Relieving constipation
Allowing the adolescent to make decisions about whether or not to take medication
Verbalizing the importance of monitoring for medication side effects
Developing alternative educational goals
The Correct Answer is C
Verbalizing the importance of monitoring for medication side effects.
Graves’ disease is an autoimmune disorder that causes hyperthyroidism, which means the thyroid gland produces too much thyroid hormone. This can lead to symptoms such as weight loss, increased appetite, nervousness, irritability, insomnia, heat intolerance, and palpitations. The medication methimazole is used to treat Graves’ disease by blocking the synthesis of thyroid hormone. However, methimazole can also cause serious side effects such as liver damage, agranulocytosis (low white blood cell count), and allergic reactions.
Therefore, the priority nursing goal for a 14 year old diagnosed with Graves’ disease is to verbalize the importance of monitoring for medication side effects and reporting them to the health care provider.
Choice A is wrong because relieving constipation is not a priority goal for Graves’ disease. Constipation is more likely to occur in hypothyroidism, which is the opposite of hyperthyroidism.
Choice B is wrong because allowing the adolescent to make decisions about whether or not to take medication is not a priority goal for Graves’ disease. While it is important to respect the adolescent’s autonomy and involve them in their care plan, they also need to understand the risks and benefits of taking medication and the consequences of not taking it.
Choice D is wrong because developing alternative educational goals is not a priority goal for Graves’ disease. Graves’ disease can affect the academic performance of adolescents due to cognitive and emotional changes caused by hyperthyroidism.
However, this does not mean that they need to change their educational goals. They may need extra support and accommodations from their teachers and parents to cope with their condition and achieve their potential.
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Related Questions
Correct Answer is B
Explanation
Measles (rubeola) is a communicable disease that is characterized by Koplik’s spots, which are clustered, white lesions on the buccal mucosa opposite the lower molars. They appear two to three days before the measles rash and are pathognomonic for measles.
Choice A is wrong because rubella is a different viral infection that causes a mild rash and fever, but does not have Koplik’s spots.
Choice C is wrong because chickenpox (varicella) is caused by the varicella-zoster virus and produces fluid-filled blisters on the skin, not white spots in the mouth.
Choice D is wrong because exanthema subitum (roseola) is caused by the human herpesvirus 6 or 7 and causes a high fever followed by a pink rash on the trunk and neck, but no oral lesions.
Correct Answer is C
Explanation
Placing eye shields over the newborn’s closed eyes. This is because phototherapy can cause eye damage and irritation to the newborn, so eye protection is essential.
Choice A is wrong because oil-based lotion can increase the absorption of heat and cause burns to the newborn’s skin.
Choice B is wrong because limiting the newborn’s intake of milk can cause dehydration and increase the risk of hyperbilirubinemia.
Choice D is wrong because changing the newborn’s position every 4 hours is not frequent enough to prevent pressure ulcers and ensure even exposure to the light.
Normal ranges for bilirubin levels in newborns are 1 to 12 mg/dL for term infants and 3 to 14 mg/dL for preterm infants. Phototherapy is usually indicated when the bilirubin level exceeds 15 mg/dL for term infants and 10 mg/dL for preterm infants.
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