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. Hyperglycemia. While elevated blood glucose can occur in acute pancreatitis due to pancreatic inflammation impairing insulin secretion, it is not an electrolyte imbalance. The question specifically asks about electrolyte-related manifestations.
B. Hypotension. Hypotension in acute pancreatitis is often due to fluid shifts (third-spacing) and systemic inflammation, rather than a direct electrolyte imbalance. Though dehydration and electrolyte losses can contribute to hypotension, this is not the most specific sign of an electrolyte disturbance.
C. Paralytic ileus and abdominal distention. Hypokalemia can lead to paralytic ileus, but ileus and distention are also caused by peritoneal irritation, inflammation, and impaired motility due to pancreatitis itself. While potassium imbalance could contribute, this is not the most direct electrolyte-related symptom.
D. Muscle twitching and digit numbness. Hypocalcemia is a common electrolyte imbalance in acute pancreatitis, caused by fatty acid breakdown binding calcium, leading to saponification. This results in neuromuscular excitability, causing muscle twitching, paresthesia (numbness/tingling), and positive Chvostek’s or Trousseau’s signs. These symptoms are clear indicators of an electrolyte disturbance related to pancreatitis.
Correct Answer is C
Explanation
A. Oxygenate before suctioning. Pre-oxygenation before suctioning is essential to prevent hypoxia and bradycardia, but it does not directly ensure that the ETT remains in the correct position. This is a general airway management guideline rather than a specific intervention to maintain ETT placement.
B. Auscultate bilateral breath sounds. Auscultation is important for ongoing assessment of lung sounds and oxygenation but does not physically prevent tube displacement. While listening for equal breath sounds helps detect tube migration or mainstem bronchus intubation, it does not secure the ETT in place.
C. Firmly secure the ETT in place. After proper ETT placement is confirmed with a chest x-ray, securing the tube with adhesive tape or a commercial ETT holder prevents displacement. Unintentional extubation or tube migration can lead to hypoxia, respiratory distress, or esophageal intubation, making proper tube fixation a priority intervention.
D. Suction the ETT every 2 hours. Routine suctioning is not recommended unless there are indications such as visible secretions, high airway pressures, or decreased oxygenation. Frequent, unnecessary suctioning can cause mucosal trauma, hypoxia, and bradycardia and does not help maintain ETT placement.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.