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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
choice D. Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia. This is because a macrosomic infant (a newborn who’s much larger than average) is at risk of developing low blood sugar levels after birth, especially if the mother has diabetes. Hypoglycemia can cause neurological damage in the newborn, so it is important to detect and treat it promptly.
Choice A is wrong because leaving the infant in the room with the mother without monitoring the blood glucose levels may miss signs of hypoglycemia and delay treatment.
Choice B is wrong because taking the infant immediately to the nursery may separate the infant from the mother and interfere with breastfeeding, which can help prevent hypoglycemia.
Choice C is wrong because performing a gestational age assessment to determine whether the infant is large for gestational age is not urgent and does not address the risk of hypoglycemia.
Normal ranges for blood glucose levels in term infants are 2.6 mmol/L or higher at any time. A blood glucose level of 2.5 mmol/L or less is considered hypoglycemic.
Correct Answer is E
Explanation
The presence or absence of anxiety is a noninvasive assessment that the RN would perform to evaluate the patient’s psychological status and possible signs of hypovolemic shock.
Anxiety can indicate reduced cerebral perfusion due to blood loss and low blood pressure.
Choice A is wrong because pulse oximetry is a noninvasive assessment that the RN would perform to measure the oxygen saturation of the patient’s blood, not the circulatory status.
Choice B is wrong because heart sounds are a noninvasive assessment that the RN would perform to auscultate the cardiac rhythm and rate of the patient, not the circulatory status.
Choice C is wrong because arterial pulses are a noninvasive assessment that the RN would perform to palpate the strength and quality of the patient’s peripheral pulses, not the circulatory status.
Choice D is wrong because skin color, temperature, and turgor are noninvasive assessments that the RN would perform to observe the skin integrity and hydration of the patient, not the circulatory status.
Normal ranges for pulse oximetry are 95% to 100%, for heart rate are 60 to 100 beats per minute, and for blood pressure are 120/80 mmHg.
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