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 C
Explanation
A. Determine patellar tendon reflex response. The patellar reflex (knee jerk) assesses function of the L2-L4 spinal nerves, which are below the level of injury (C8-T1) and do not provide information about upper extremity function. While deep tendon reflexes are important, they do not help assess function at the suspected injury level.
B. Check the urinary bladder for distention. Bladder function is controlled by the sacral spinal nerves (S2-S4), which are much lower than the injury level. While bladder dysfunction is common in spinal cord injuries, it does not assess C8-T1 nerve function specifically.
C. Ask the client to grasp an object or form a fist. The C8 and T1 spinal nerves control hand and finger movements, including grip strength. Testing the client’s ability to grasp an object or form a fist helps assess fine motor function and nerve integrity at the injury level. This is the most appropriate way to determine function in the lower cervical and upper thoracic spinal nerves.
D. Apply resistance while the client lifts the legs. Leg movement is controlled by the lumbar and sacral spinal nerves (L2-S2), which are below the injury level. Assessing leg strength does not provide relevant information about C8-T1 function.
Correct Answer is ["C","E","F"]
Explanation
A. White blood cell differential. Although infection is a common precipitating factor for DKA, an elevated WBC count is common in DKA due to stress, dehydration, and inflammation rather than infection itself. While a WBC differential may be done if infection is suspected, it is not a primary test for DKA management.
B. Hemoglobin A1C. Hemoglobin A1C (HbA1c) reflects long-term glucose control (past 2-3 months) but does not provide immediate information about the current metabolic status or severity of DKA. While it may be useful in assessing overall diabetes management, it is not essential for acute DKA treatment.
C. Serum electrolytes. Patients with DKA experience significant electrolyte imbalances, particularly potassium depletion due to osmotic diuresis and insulin deficiency. Monitoring serum sodium, potassium, and bicarbonate is crucial for guiding fluid and electrolyte replacement therapy. Potassium levels may appear normal or high initially due to acidosis but typically drop with insulin administration.
D. Urine culture. A urine culture is only indicated if a urinary tract infection (UTI) is suspected as a trigger for DKA. However, routine urine culture is not required in every case of DKA unless there are symptoms of infection such as fever, dysuria, or pyuria.
E. Anion gap. DKA is a form of high anion gap metabolic acidosis, caused by the accumulation of ketones. The anion gap (AG) is calculated as (Na⁺ - [Cl⁻ + HCO₃⁻]), with a value >12 mEq/L indicating metabolic acidosis. Monitoring the anion gap helps assess the severity of acidosis and guide treatment progress, as a decreasing anion gap suggests resolution of ketosis.
F. Urine ketones. Urine ketone testing helps confirm the presence of ketoacidosis, particularly in the initial stages of DKA diagnosis. While serum beta-hydroxybutyrate is a more accurate indicator of ketone levels, urine ketones remain useful for initial screening and monitoring treatment response as they decrease with appropriate management.
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