Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
What is the priority nursing goal for a 14-year-old diagnosed with Graves’ disease?
A. Relieving constipation
This 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.
B. Allowing the adolescent to make decisions about whether or not to take medication
This 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.
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.
D. Developing alternative educational goals
This 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.
This question is an excerpt from Nurse Dive's nursing test bank - OB Pediatric Cumulative Exam Test 4 V 1 2023 Proctored Exam. Take the full exam now
Full Explanation
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.
Similar Questions
The nurse is talking to a parent of an infant with heart failure about feeding the infant. Which statement about feeding the child is correct?
A. “You may need to increase the caloric density of your infant’s formula.”.
This is because infants with heart failure have increased metabolic needs and may not be able to consume enough volume to meet their nutritional requirements. Increasing the caloric density of the formula can help them achieve adequate growth and development without overloading their heart.
B. “You should feed your baby every 2 hours.”.
This is wrong because feeding the baby every 2 hours may cause fatigue and dehydration. Infants with heart failure should be fed every 3 to 4 hours or on demand.
C. “You may need to increase the amount of formula your infant eats with each feeding.”.
This is wrong because increasing the amount of formula may cause fluid retention and worsen heart failure. Infants with heart failure should be fed small, frequent amounts of formula.
D. “You should place a nasal oxygen cannula on your infant during and after each feeding.”.
This is wrong because placing a nasal oxygen cannula on the infant during and after each feeding may not be necessary or beneficial. Oxygen therapy should be prescribed by a physician based on the infant’s oxygen saturation levels and clinical signs of hypoxia.
Full Explanation
“You may need to increase the caloric density of your infant’s formula.” This is because infants with heart failure have increased metabolic needs and may not be able to consume enough volume to meet their nutritional requirements. Increasing the caloric density of the formula can help them achieve adequate growth and development without overloading their heart.
Choice B is wrong because feeding the baby every 2 hours may cause fatigue and dehydration. Infants with heart failure should be fed every 3 to 4 hours or on demand.
Choice C is wrong because increasing the amount of formula may cause fluid retention and worsen heart failure. Infants with heart failure should be fed small, frequent amounts of formula.
Choice D is wrong because placing a nasal oxygen cannula on the infant during and after each feeding may not be necessary or beneficial. Oxygen therapy should be prescribed by a physician based on the infant’s oxygen saturation levels and clinical signs of hypoxia.
A nurse is conducting discharge and teaches parents about the care of their infant after cardiac surgery.
The nurse instructs the parents to notify the physician if the conditions occur. (Select all that apply.)
A. Respiratory rate of 36 breaths/minute at rest
This is wrong because a respiratory rate of 36 breaths/minute at rest is within the normal range for an infant.
B. Appetite slowly increasing
This is wrong because an appetite slowly increasing is a positive sign of recovery and does not require immediate attention.
C. Temperature above 37.7° C (100° F)
The parents should notify the physician if the infant has a temperature above 37.7° C (100° F). This is a sign of infection, respiratory distress, or cyanosis, which could indicate complications after cardiac surgery.
D. New, frequent coughing
The parents should notify the physician if the infant has new frequent coughing. This is a signof infection, respiratory distress, or cyanosis, which could indicate complications after cardiac surgery.
E. Turning blue or bluer than normal
The parents should notify the physician if the infant has turned blue or bluer than normal. These are signs of infection, respiratory distress, or cyanosis, which could indicate complications after cardiac surgery.
Full Explanation
The parents should notify the physician if the infant has a temperature above 37.7° C (100° F), new frequent coughing, or turning blue or bluer
than normal. These are signs of infection, respiratory distress, or cyanosis, which could indicate complications after cardiac surgery.
Choice A is wrong because a respiratory rate of 36 breaths/minute at rest is within the normal range for an infant.
Choice B is wrong because an appetite slowly increasing is a positive sign of recovery and does not require immediate attention.
When caring for an infant with an upper respiratory tract infection and elevated temperature, which appropriate nursing intervention should the nurse implement?
A. Give tepid water baths to reduce fever.
This is wrong because tepid water baths are not recommended for fever reduction. They can cause shivering, which increases heat production and can raise the temperature further. Instead, antipyretics such as acetaminophen or ibuprofen can be given as prescribed.
B. Encourage food intake to maintain caloric needs.
This is wrong because food intake may be decreased due to poor appetite, difficulty breathing, or sore throat. Forcing food intake can cause vomiting or aspiration. Fluid intake is more important than caloric intake during an acute infection.
C. Have child wear heavy clothing to prevent chilling.
This is wrong because heavy clothing can increase heat retention and discomfort. The infant should be dressed in light clothing and the room temperature should be comfortable.
D. Give small amounts of favorite fluids frequently to prevent dehydration.
Dehydration is a common complication of upper respiratory tract infections in infants, especially if they have a fever. Giving small amounts of fluids frequently can help maintain hydration and electrolyte balance.
Full Explanation
Give small amounts of favorite fluids frequently to prevent dehydration.
Dehydration is a common complication of upper respiratory tract infections in infants, especially if they have a fever. Giving small amounts of fluids frequently can help maintain hydration and electrolyte balance.
Some additional information about the other choices are:
Choice A is wrong because tepid water baths are not recommended for fever reduction. They can cause shivering, which increases heat production and can raise the
temperature further. Instead, antipyretics such as acetaminophen or ibuprofen can be given as prescribed.
Choice B is wrong because food intake may be decreased due to poor appetite, difficulty breathing, or sore throat. Forcing food intake can cause vomiting or aspiration. Fluid intake is more important than caloric intake during an acute infection.
Choice C is wrong because heavy clothing can increase heat retention and discomfort. The infant should be dressed in light clothing and the room temperature should be comfortable.