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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.

Exhibits

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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is []

Explanation

Place the call light within the client's reach. The client has undergone surgery on the left hemisphere of the brain, which controls speech and motor function on the right side. This may lead to temporary weakness or speech difficulties, making it essential to ensure easy access to the call light for assistance.
Use a word board to help the client communicate. Damage to the left hemisphere can result in Broca aphasia, where the client has difficulty producing speech but can still understand language. A word board or communication aid allows the client to express needs effectively despite speech limitations.
Cerebral perfusion pressure. Monitoring cerebral perfusion pressure (CPP) is essential after brain surgery to ensure the brain is receiving adequate blood flow. Low CPP can lead to ischemia, while high CPP may indicate increased intracranial pressure (ICP), both of which can result in serious complications.
Level of consciousness. Assessing neurological status frequently helps detect early signs of deterioration, such as worsening intracranial pressure, cerebral edema, or postoperative bleeding. Changes in alertness, responsiveness, or confusion may indicate a need for urgent intervention.
Broca aphasia. Since the left hemisphere controls speech production, surgery in this area may cause Broca aphasia, where the client understands language but struggles to form words or complete sentences. The use of alternative communication methods is necessary to assist the client in expressing their needs.
Prepare the client to return to surgery. There is no indication of complications requiring an immediate return to the operating room. The estimated blood loss (100 mL) is minimal, and vital signs remained stable throughout the procedure.
Give ibuprofen as ordered. Ibuprofen (a nonsteroidal anti-inflammatory drug - NSAID) is contraindicated postoperatively because it can increase the risk of bleeding by inhibiting platelet function. Acetaminophen is typically preferred for pain control.
Elevate the head of the bed to 45 degrees. After brain surgery, the head of the bed should be elevated to 30 degrees, not 45 degrees. This optimizes cerebral venous drainage while preventing excessive intracranial pressure (ICP) changes that could impair perfusion.
White blood cell count. WBC count may be monitored for infection, but immediate concerns after brain surgery focus on neurological status and cerebral perfusion rather than infection unless symptoms of fever or worsening condition develop.
Pupil response. While pupil assessment is a key neurological parameter, it is more relevant for clients at risk of brain herniation or severe ICP elevation. In this case, monitoring level of consciousness and cerebral perfusion pressure takes priority.
Deep tendon reflexes. Reflex testing is not a primary concern after brain surgery unless there are signs of spinal cord involvement or a progressive neurological disorder. Monitoring motor function and speech ability is more relevant.
Myasthenia gravis. Myasthenia gravis is an autoimmune neuromuscular disorder that causes muscle weakness but is unrelated to brain tumor removal.
Cushing response. Cushing's response is a late sign of increased intracranial pressure (ICP), characterized by hypertension, bradycardia, and irregular respirations. The client has no signs of worsening ICP at this time.
Hydrocephalus. Hydrocephalus is excess cerebrospinal fluid (CSF) accumulation, which typically requires a shunt or external ventricular drain (EVD). There is no indication of CSF buildup in this client.

A. Increase the fraction of inspired oxygen B. Collect equipment for a needle aspiration C. Replace the ventilator D. Measure the nasogastric tube output E. Place the client in Trendelenburg

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

Increase the fraction of inspired oxygen (FiO₂). The client has severe COVID pneumonia and is on mechanical ventilation with high inspiratory pressures, suggesting acute respiratory distress syndrome (ARDS). Increasing FiO₂ is indicated if oxygenation is inadequate (e.g., low PaO₂ or SpO₂). However, oxygen toxicity should be avoided, so adjustments should be made based on arterial blood gases (ABGs) and oxygen saturation.
Collect equipment for a needle aspiration. Needle aspiration is typically used for pneumothorax management, but there is no mention of clinical signs such as sudden hypotension, absent breath sounds, or tracheal deviation. While ventilated COVID-19 patients are at risk for barotrauma, this procedure is not justified without evidence of pneumothorax.
Replace the ventilator. There is no indication that the ventilator is malfunctioning or that the settings are inappropriate. If ventilation issues arise (e.g., high plateau pressures, auto-PEEP, or ventilator asynchrony), adjustments to settings, sedation, or lung-protective strategies should be considered before replacing the ventilator.
Measure the nasogastric tube output. The client is intubated and sedated, meaning they cannot protect their airway or tolerate oral intake. A nasogastric (NG) tube is commonly placed for gastric decompression and feeding. Monitoring NG output is essential to assess for gastrointestinal bleeding, ileus, or high residual volumes, which can affect feeding tolerance.
Place the client in Trendelenburg. The Trendelenburg position increases the risk of aspiration, impairs lung expansion, and worsens ventilation-perfusion mismatch, especially in ARDS patients. Instead, prone positioning is often preferred in severe COVID pneumonia to improve oxygenation and alveolar recruitment.

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Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

Exhibits Click to mark whether the actions are indicated, contraindicated, or nonessential for this client. Each row must have one option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

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A client, who is 4 hours postoperative laparotomy, has rapidly increasing abdominal distention with elevated pulse and respiratory rates. The client's skin is cool and pale, and there is no change in the blood pressure. Which intervention should the nurse implement immediately?

The nurse assesses a client postoperatively who has an arterial line in the right radial artery. Assessment findings include pallor, paresthesia, and slow capillary refill in the client's right-hand fingers. Which action should the nurse take?

Exhibits Which are three goals of therapy for this client?

A client who is admitted to the intensive care unit (ICU) with acute decompensated heart failure is receiving a continuous infusion of milrinone via a subclavian venous catheter. Which action should the nurse take when preparing to administer the first dose of IV furosemide?