A client with a history of Addison's disease and flu-like symptoms accompanied by nausea and vomiting over the past week is brought to the facility. His wife reports that he acted confused and was extremely weak when he awoke that morning. The client's blood pressure is 90/58 mm Hg, his pulse is 116 beats/minute, and his temperature is 101° F (38.3° C). A diagnosis of acute adrenal insufficiency is made. What should the nurse expect to administer by I.V. infusion?
Methylprednisolone (Solu-medrol)
Hypotonic saline
Potassium (K-dur)
Regular Insulin
The Correct Answer is A
A. Methylprednisolone (Solu-medrol):
Explanation: Acute adrenal insufficiency is a life-threatening condition characterized by a sudden deficiency of adrenal hormones. In this situation, intravenous glucocorticoids such as methylprednisolone are administered to replace the deficient hormones and stabilize the patient. This is the appropriate intervention to address the acute adrenal crisis.
B. Hypotonic saline:
Explanation: Hypotonic saline is not the first-line treatment for acute adrenal insufficiency. The priority is to replace glucocorticoids to address the adrenal hormone deficiency.
C. Potassium (K-dur):
Explanation: While electrolyte imbalances can occur in adrenal insufficiency, potassium replacement alone does not address the primary issue of glucocorticoid deficiency in acute adrenal insufficiency.
D. Regular Insulin:
Explanation: Regular insulin is not the primary treatment for acute adrenal insufficiency. Glucocorticoid replacement, such as methylprednisolone, is the key intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Avoid the use of moisturizing lotions.
This statement is not a priority instruction. Moisturizing lotions, especially those designed for diabetic foot care, can help prevent dry skin and complications. However, it's crucial to choose appropriate, diabetes-friendly moisturizers.
B. Examine feet weekly for redness, blisters, and abrasions.
This is an important and relevant instruction. Regular foot inspections help detect any signs of injury or infection early, preventing complications, especially for individuals with peripheral neuropathy.
C. Dry feet vigorously after each bath.
This statement is not advisable. Vigorous drying can potentially harm the skin, especially for individuals with diabetes. A gentle and thorough drying is recommended to prevent skin damage.
D. Avoid hot-water bottles and heating pads.
This is a priority instruction. Patients with peripheral neuropathy may have reduced sensation in their feet, making them more susceptible to burns. Avoiding sources of excessive heat helps prevent injuries.
Correct Answer is B
Explanation
A. Monitoring the patient's breathing and reviewing the patient's arterial blood gases:
Rationale: While respiratory status is crucial in any patient assessment, arterial blood gases primarily evaluate respiratory function. Neutropenia directly affects the immune system, not respiratory function.
Appropriateness: Not directly related to assessing neutropenia.
B. Monitoring the patient's temperature and reviewing the patient's complete blood count with differential:
Rationale: Neutropenia can cause fever due to the increased risk of infection. Monitoring temperature and reviewing the complete blood count (CBC) with differential, specifically the neutrophil count, is essential in evaluating neutropenia and identifying potential infections.
Appropriateness: Correct. Monitoring temperature and reviewing CBC with differential are crucial in assessing neutropenia.
C. Monitoring the patient's blood pressure and reviewing the patient's hematocrit:
Rationale: Blood pressure assessment and hematocrit evaluation are essential aspects of general patient care but are not specific to neutropenia.
Appropriateness: Not directly related to assessing neutropenia.
D. Monitoring the patient's heart rate and reviewing the patient's hemoglobin:
Rationale: Heart rate monitoring and hemoglobin assessment are crucial in various clinical situations but are not specific indicators of neutropenia.
Appropriateness: Not directly related to assessing neutropenia.
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