A 55-year-old male client is brought to the emergency department by his spouse due to sudden weakness, dizziness, and confusion. The spouse states that the client has had persistent fatigue and nausea for the past few days but suddenly became disoriented and lethargic this morning. The client also reports severe abdominal pain and muscle cramps.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Answer:
Potential Condition:
Acute Adrenal Crisis
- The client has a history of Addison’s disease (chronic steroid use) and recent illness with vomiting, leading to decreased oral intake and medication noncompliance.
- Symptoms such as hypotension (80/50 mmHg), tachycardia (115 bpm), confusion, nausea, vomiting, and abdominal pain are classic signs of acute adrenal insufficiency.
Actions to Take:
Bolus Intravenous Fluids
- Fluid resuscitation with 0.9% normal saline is critical to restore intravascular volume and correct hypotension due to adrenal insufficiency.
Check Blood Glucose
- Hypoglycemia is a common complication of adrenal crisis due to cortisol deficiency, requiring close monitoring and possible glucose administration.
Parameters to Monitor:
Blood Pressure
- Hypotension is a hallmark of adrenal crisis and must be monitored closely to assess response to fluid resuscitation and steroid therapy.
Electrolytes
- Clients with adrenal crisis often have hyponatremia and hyperkalemia due to aldosterone deficiency, requiring frequent electrolyte monitoring.
Incorrect Choices:
Potential Conditions:
- Ketoacidosis: More common in diabetes, presents with high blood glucose and ketonuria.
- Diabetes Insipidus: Causes polyuria and dehydration but lacks hypotension and hyperkalemia.
- Myxedema: Linked to hypothyroidism, causing bradycardia and hypothermia, not hypotension and hyperkalemia.
Actions to Take:
- Hold hydrocortisone dose: Steroid replacement is necessary, not withholding it.
- Collect urine for a urinalysis: Not a priority; adrenal crisis is diagnosed via history, symptoms, and labs.
- Change intravenous fluids to 0.45%: Hypotension requires 0.9% normal saline, not hypotonic fluids.
Parameters to Monitor:
- Urine output: Useful but less critical than blood pressure and electrolytes in adrenal crisis.
- Thyroid stimulating hormone: Relevant for hypothyroidism, not adrenal insufficiency.
- Heart rate: Tachycardia is expected but is not the most critical indicator of improvement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Suction subglottic area above the ETT cuff before entering the ETT. While subglottic suctioning helps prevent ventilator-associated pneumonia (VAP) by removing pooled secretions, it does not directly improve oxygenation during deep endotracheal suctioning. The priority is to optimize oxygenation before and after suctioning.
B. Use the ventilator settings to stack breaths prior to suctioning. Pre-oxygenating the client by delivering additional breaths via the ventilator helps prevent hypoxia during suctioning. Closed suction systems momentarily interrupt airflow, which can lead to oxygen desaturation. Providing 100% FiO₂ for 30–60 seconds before suctioning helps ensure adequate oxygenation and reduces complications.
C. Rinse suction catheters with normal saline between each suction pass. Flushing the catheter keeps it clean and patent, but it does not enhance oxygenation. Normal saline instillation before suctioning is not recommended, as it can increase infection risk and worsen secretion mobilization.
D. Suction for 30 seconds with each pass of the suction catheter. Prolonged suctioning can cause severe hypoxia, bradycardia, and airway trauma. Suction passes should be limited to 10–15 seconds to minimize complications. If additional suctioning is needed, the client should be reoxygenated between passes.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}
Explanation
- I will monitor my urine output and pay attention to the volume and color. Clients with DI must monitor urine output closely because polyuria and diluted urine indicate under-treatment, while sudden reduced output and darker urine may suggest fluid retention or excessive desmopressin dosing.
- I will always wear my medical alert bracelet. A medical alert bracelet is essential for emergency situations since DI can lead to severe dehydration and electrolyte imbalances if left untreated. It ensures that emergency responders are aware of the condition if the client is unable to communicate.
- I will use the same scale and wear a similar amount of clothing when I take my weekly weight. Monitoring body weight trends is crucial in DI management, as sudden weight gain may indicate fluid retention (over-treatment), while weight loss may suggest dehydration. Using a consistent method ensures accurate tracking.
- If I gain more than 2.2 lb (1 kg), I will go to the emergency department (ED). A sudden weight gain may suggest fluid retention from over-treatment, but mild fluctuations are not always an emergency. Instead, the client should report significant weight changes to their healthcare provider to assess medication adjustments.
- If I become thirstier, I may need another dose of the medication. While increased thirst may indicate under-treatment, self-adjusting the desmopressin dose is not recommended without consulting a healthcare provider. The client should track symptoms and report persistent thirst to determine if a dosage change is necessary.
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