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 D
Explanation
A. Measure the client's abdominal girth. While tracking abdominal distension is useful, it does not address the underlying cause of the client's deterioration. Measuring girth should not delay immediate intervention for a potentially life-threatening condition.
B. Monitor the client's recent hemoglobin levels. A drop in hemoglobin would indicate internal bleeding, but waiting for lab results could delay necessary treatment. The client is already showing signs of early shock, requiring urgent medical intervention rather than just monitoring.
C. Prepare for nasogastric tube (NGT) insertion. An NGT may be needed for bowel obstruction or paralytic ileus, but the client's worsening condition suggests a more urgent issue, such as intra-abdominal hemorrhage. Addressing the potential bleeding takes priority over decompression.
D. Notify the healthcare provider (HCP) of the client's status. The client's tachycardia, tachypnea, cool pale skin, and worsening abdominal distension suggest early shock, likely due to postoperative internal bleeding or abdominal compartment syndrome. Immediate notification of the HCP ensures rapid assessment, diagnostic testing, and potential emergency intervention to prevent further deterioration.
Correct Answer is C
Explanation
A. Temperature. While temperature monitoring is important in septic shock to assess infection control, it is not an indicator of dopamine's effectiveness. Dopamine primarily affects renal perfusion and blood pressure, not body temperature regulation.
B. Heart sounds. Dopamine is a vasopressor and inotropic agent, but it does not directly impact heart sounds. While it can increase myocardial contractility, assessing blood pressure and perfusion parameters is more relevant in evaluating its therapeutic effects.
C. Urinary output. Low-dose dopamine (1-5 mcg/kg/min) primarily acts as a dopaminergic agonist, increasing renal blood flow and urine output by dilating renal arteries. In septic shock, maintaining adequate kidney perfusion is critical to prevent acute kidney injury (AKI). A therapeutic response to dopamine would be seen as improved urinary output (≥ 30 mL/hr), indicating effective renal perfusion.
D. Pupil response. Dopamine does not directly affect pupil size or reactivity. Pupil assessment is more relevant in neurological evaluations, not in monitoring the effects of dopamine in septic shock.
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