A client with a history of adrenal insufficiency is admitted to the intensive care unit with an acute adrenal crisis. The client is complaining of nausea and joint pain.
Vital signs are: temperature 102° F (38.9° C), heart rate 138 beats/minute, blood pressure 80/60 mm Hg. Which intervention should the nurse implement first?
Obtain an analgesic prescription.
Infuse an intravenous fluid bolus.
Administer PRN oral antipyretic.
Cover client with a cooling blanket.
The Correct Answer is B
Choice A rationale
While obtaining an analgesic prescription might help to alleviate the client’s joint pain, it is not the first intervention that should be implemented. The client’s vital signs indicate that they are in a state of shock, which is a medical emergency.
Choice B rationale
Infusing an intravenous fluid bolus is often the first step in treating shock. The client’s low blood pressure and high heart rate suggest that they may be experiencing hypovolemic shock, which can be caused by a severe fluid loss. Administering fluids can help to increase blood volume and improve blood pressure.
Choice C rationale
Administering a PRN oral antipyretic would not address the client’s immediate need. The client’s high temperature is a concern, but the low blood pressure and high heart rate are more immediate concerns.
Choice D rationale
Covering the client with a cooling blanket would address the client’s high temperature, but it would not address the more immediate concerns of low blood pressure and high heart rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A firm crib mattress is crucial in reducing the risk of Sudden Infant Death Syndrome (SIDS). Soft surfaces can conform to the infant’s face and potentially block their airway, leading to suffocation.
Choice B rationale
Propping the infant with a pillow when in a side-lying position is not recommended as it increases the risk of SIDS. Infants should always be placed on their backs to sleep.
Choice C rationale
Swaddling the infant in a blanket for sleeping is not the most important measure to prevent SIDS. Overheating and loose bedding are risk factors for SIDS23.
Choice D rationale
Placing the infant in a prone position whenever possible is not recommended. Infants should always be placed on their backs to sleep to reduce the risk of SIDS23.
Correct Answer is B
Explanation
Choice A rationale
Osteoarthritis is a type of arthritis that occurs when the cartilage that cushions the ends of your bones in your joints gradually deteriorates. Osteoarthritis symptoms often develop slowly and worsen over time. They can include: Pain in the joint during or after use, or after periods of inactivity, Tenderness in the joint when you apply light pressure to or near it, Stiffness in the joint, that may be most noticeable when you wake up in the morning or after a period of inactivity, Loss of flexibility in the joint, Grating sensation or sound when you use the joint. But in this case, the client’s symptoms do not align with those of osteoarthritis.
Choice B rationale
Rheumatoid Arthritis is a chronic inflammatory disorder that can affect more than just your joints. In some people, the condition can damage a wide variety of body systems, including the skin, eyes, lungs, heart and blood vessels. Signs and symptoms of rheumatoid arthritis may include: Tender, warm, swollen joints, Joint stiffness that is usually worse in the mornings and after inactivity, Fatigue, fever and loss of appetite. The client’s symptoms align with those of Rheumatoid Arthritis.
Choice C rationale
Carpal Tunnel Syndrome is a condition that causes numbness, tingling and other symptoms in the hand and arm. Carpal tunnel syndrome is caused by a compressed nerve in the carpal tunnel, a narrow passageway on the palm side of your wrist. The anatomy of your wrist, health problems and possibly repetitive hand motions can contribute to carpal tunnel syndrome. But in this case, the client’s symptoms do not align with those of Carpal Tunnel Syndrome.
Choice D rationale
Gout is a common and complex form of arthritis that can affect anyone. It’s characterized by sudden, severe attacks of pain, swelling, redness and tenderness in the joints, often the joint at the base of the big toe. An attack of gout can occur suddenly, often waking you up in the middle of the night with the sensation that your big toe is on fire. The affected joint is hot, swollen and so tender that even the weight of the sheet on it may seem intolerable. But in this case, the client’s symptoms do not align with those of Gout.
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