A client has an acute adrenal (addisonian) crisis. Which observation is the most significant during the nursing assessment?
Serum glucose 158 mg/dL (8.77 mmol/L)
Blood pressure 98/52 mm Hg
Weight gain 3 pounds (1.36 kg) in 24 hours
Insomnia and restlessness
The Correct Answer is B
Choice A reason: Serum glucose 158 mg/dL (8.77 mmol/L) is not the most significant observation for an acute adrenal crisis, but a mild elevation of blood sugar. A mild elevation of blood sugar may occur due to stress, infection, medication, or diet, among other factors. It does not indicate a severe deficiency of adrenal hormones, which is the cause of an acute adrenal crisis.
Choice B reason: Blood pressure 98/52 mm Hg is the most significant observation for an acute adrenal crisis, as it indicates a condition called hypotension. Hypotension is a low blood pressure that may cause dizziness, fainting, shock, or organ failure. It is a sign of an acute adrenal crisis, which is a life-threatening emergency that occurs when the adrenal glands fail to produce enough cortisol and aldosterone. Cortisol and aldosterone are hormones that regulate blood pressure, blood sugar, and electrolyte balance.
Choice C reason: Weight gain 3 pounds (1.36 kg) in 24 hours is not the most significant observation for an acute adrenal crisis, but a possible sign of fluid retention. Fluid retention may occur due to heart failure, kidney disease, liver disease, or medication, among other causes. It does not indicate a severe deficiency of adrenal hormones, which is the cause of an acute adrenal crisis.
Choice D reason: Insomnia and restlessness are not the most significant observations for an acute adrenal crisis, but possible symptoms of anxiety, stress, or hyperthyroidism. Anxiety, stress, and hyperthyroidism may cause difficulty sleeping, nervousness, or agitation, among other effects. They do not indicate a severe deficiency of adrenal hormones, which is the cause of an acute adrenal crisis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: "My feet swell up during the evening." is not a specific statement for systolic heart failure, but a general sign of fluid retention. Fluid retention may occur in both systolic and diastolic heart failure, as well as other conditions such as kidney disease, liver disease, or venous insufficiency.
Choice B reason: "It's harder to breathe during hot and humid weather." is not a specific statement for systolic heart failure, but a common complaint of many people with respiratory problems. Hot and humid weather may increase the workload of the lungs and the heart, but it does not indicate a reduced ejection fraction, which is the hallmark of systolic heart failure.
Choice C reason: "I wake up at night being short of breath." is the best statement for systolic heart failure, as it indicates a condition called paroxysmal nocturnal dyspnea. Paroxysmal nocturnal dyspnea is a sudden onset of breathlessness that occurs during sleep, usually due to fluid accumulation in the lungs. It is a sign of left-sided systolic heart failure, which is a failure of the left ventricle to pump blood effectively to the body.
Choice D reason: "I have stomach pain that is worse after meals." is not a specific statement for systolic heart failure, but a possible symptom of gastrointestinal disorders. Stomach pain may be caused by gastritis, ulcers, gallstones, or pancreatitis, among other conditions. It does not reflect the cardiac function or output, which are impaired in systolic heart failure.
Correct Answer is D
Explanation
Choice A reason: A sacculated aneurysm in the circle of Willis is not the most likely cause of a left-sided embolic stroke. A sacculated aneurysm is a bulging of a weak spot in the wall of an artery, which may occur in the circle of Willis, a network of arteries at the base of the brain. A sacculated aneurysm may cause a hemorrhagic stroke, which is a bleeding into the brain, not an embolic stroke, which is a blockage of a blood vessel by a clot.
Choice B reason: Rupture of small cerebral blood vessels is not the most likely cause of a left-sided embolic stroke. Rupture of small cerebral blood vessels may occur due to hypertension, diabetes, or aging, which may damage the integrity of the blood vessel walls. Rupture of small cerebral blood vessels may cause a hemorrhagic stroke, which is a bleeding into the brain, not an embolic stroke, which is a blockage of a blood vessel by a clot.
Choice C reason: Diffuse inflammation of the small diameter blood vessels is not the most likely cause of a left-sided embolic stroke. Diffuse inflammation of the small diameter blood vessels may occur due to vasculitis, which is an autoimmune disorder that causes inflammation and narrowing of the blood vessels. Diffuse inflammation of the small diameter blood vessels may cause a thrombotic stroke, which is a formation of a clot within the blood vessel, not an embolic stroke, which is a blockage of a blood vessel by a clot that travels from another site.
Choice D reason: Migration of a clot from the left atrium of the heart is the best explanation for the most likely cause of a left-sided embolic stroke. An embolic stroke is a type of ischemic stroke, which is a lack of blood flow to the brain due to a blockage of a blood vessel by a clot. A clot may form in the left atrium of the heart due to conditions such as atrial fibrillation, which is an irregular heartbeat that causes blood to pool and clot in the heart. A clot may then break off and travel through the bloodstream until it reaches a smaller blood vessel in the brain, where it causes an embolic stroke.
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