7. Surgery has been delayed for a client with Graves' disease. The correct nursing actions while waiting for the operating room to call should be:
Select all that apply.
7. Surgery has been delayed for a client with Graves' disease. The correct nursing actions while waiting for the operating room to call should be:
Select all that apply.
. Pad the side rails of the bed as the risk of seizures may increase.
. Offer the client a high-protein meal supplement to prevent hypoglycemia.
. Offer mouth care as NPO status may cause oral dryness.
. Anticipate the cleansing enema order will need to be repeated.
. Monitor the client closely for a positive Chvostek's sign.
. Apply artificial tears to prevent eye irritation.
Test-Taking Tip
Think about client comfort measures during the wait.
Content Area: Adult Health, Endocrine; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Basic Care and Comfort/Personal Hygiene
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Answer 1 is incorrect because there is no risk of seizures with hyperthyroidism. Answer 2 is incorrect because the client is NPO to prevent potential vomiting and aspiration during surgery. Answer 3 is correct because prolonged NPO status will increase dryness of the mouth. Oral care increases client comfort. Answer 4 is incorrect because a cleansing enema is required only for GI surgery. Answer 5 is incorrect because Chvostek's sign occurs with hypocalcemia, not hyperthyroidism. Postoperatively this would be part of the assessment. Answer 6 is correct because hyperthyroidism may cause exophthalmos and drops would be soothing.