A client with a history of a bilateral adrenalectomy is admitted with a weak, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse?

Decreased urinary output.

Profound weight gain.

Low blood glucose levels.

Ventricular arrhythmias.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Decreased urinary output: While decreased output may signal fluid imbalance or poor perfusion, it is not as immediately life-threatening as a cardiac arrhythmia. It should be monitored, but other findings take precedence in an acute setting.

B. Profound weight gain: Rapid weight gain suggests fluid retention, possibly from corticosteroid imbalance, but it does not pose an immediate danger compared to cardiac instability. It requires intervention but is not emergent.

C. Low blood glucose levels: Hypoglycemia is common after adrenalectomy due to cortisol deficiency and must be treated, but symptoms often develop gradually and are managed with glucose replacement. It is serious but not as acutely life-threatening as arrhythmias.

D. Ventricular arrhythmias: This finding indicates severe electrolyte disturbances—especially hyperkalemia, which can occur after adrenalectomy due to aldosterone deficiency. It poses an immediate threat to cardiac function and requires urgent intervention.

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Correct Answer is C

Explanation

Rationale:

A. Immunosuppressive therapy:This is a common treatment for aplastic anemia when a matched donor is unavailable, especially in older children and adults. However, it is less curative and carries a higher risk of relapse compared to bone marrow transplantation.

B. Chemotherapy: Chemotherapy is not the primary treatment for aplastic anemia. It is mainly used in malignancies. In some cases, chemotherapy may precede transplantation or be part of immunosuppressive therapy, but it is not curative alone.

C. Bone marrow transplantation: This is the treatment of choice and offers the best prognosis, particularly in children with a matched sibling donor. It provides a potential cure by replacing the defective marrow with healthy stem cells.

D. Blood transfusions: Transfusions manage symptoms and prevent complications like anemia or bleeding but do not treat the underlying cause. Long-term use increases the risk of iron overload and alloimmunization.

A. Blood pressure of 120/74 mm Hg B. Capillary refill of 4 seconds in lower extremities C. Pedal pulse of 2+ or better D. Pupils equal and nonresponsive to light E. Absence of numbness or tingling in feet F. Skin that is pale, cool to touch G. Client has urine output of 1,600 mL in 24 hours H. Creatinine of 1.2 mg/dL (106 mmol/L)

Correct Answer is ["A","C","E","G","H"]

Explanation

Rationale for Correct Choices:

Blood pressure of 120/74 mm Hg: This is within the normal range and indicates stable cardiovascular function, which supports discharge readiness following an aortic aneurysm intervention.
Pedal pulse of 2+ or better: A 2+ pulse signifies adequate peripheral perfusion. It is important for assessing vascular integrity postoperatively, especially for patients with a history of aneurysmal disease.
Absence of numbness or tingling in feet: Normal neurovascular sensation in the lower extremities suggests intact peripheral nerve and vascular supply, a critical discharge criterion after vascular complications.
Client has urine output of 1,600 mL in 24 hours: This volume reflects adequate renal perfusion and fluid balance, within the normal range (800-2000 mL/day for adults) both of which are necessary to confirm the kidneys are functioning properly post-recovery.
Creatinine of 1.2 mg/dL (106 mmol/L): This value is within normal limits (0.6-1.2 mg/dL), indicating that renal function is preserved and not compromised by the previous cardiovascular event or interventions.

Rationale for Incorrect Choices:

Capillary refill of 4 seconds in lower extremities: A capillary refill time longer than 2–3 seconds suggests impaired perfusion, which would warrant further evaluation before discharge.
Pupils equal and nonresponsive to light: This indicates a serious neurological deficit, potentially related to brain injury or altered consciousness, and is incompatible with safe discharge.
Skin that is pale, cool to touch: This suggests possible peripheral hypoperfusion or systemic circulatory compromise and would need to be resolved before considering discharge.

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Body system	Findings
Cardiovascular	Blood pressure of 120/74 mm Hg Capillary refill of 4 seconds in lower extremities Pedal pulse of 2+ or better
Neurovascular	Pupils equal and nonresponsive to light Absence of numbness or tingling in feet Skin that is pale, cool to touch
Renal Perfusion	Client has urine output of 1,600 mL in 24 hours Creatinine of 1.2 mg/dL (106 mmol/L)

A client with a history of a bilateral adrenalectomy is admitted with a weak, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse?

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Naxlex Comprehensive Predictor Exams

A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen?

Correct Answer is C

Explanation

Correct Answer is ["A","C","E","G","H"]

Explanation

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