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?

Choice A rationale
While having a case management evaluation of the client’s home environment can provide valuable information and potential solutions for caregiving challenges, it does not directly address the caregiver’s immediate need for relief and support.

Choice B rationale

Hiring a private duty nurse could provide the caregiver with some time away from caregiving duties. However, this may not be a feasible option for many caregivers due to the cost associated with private nursing care.

Choice C rationale
Proposing that extended family could return to the area to help provide assistance assumes that such help is available and willing. This may not be the case for many caregivers.

Choice D rationale
Suggesting that social services be contacted to find a respite care facility for the client directly addresses the caregiver’s need for relief and support. Respite care provides temporary relief for primary caregivers, allowing them to rest and take care of their own needs. This can help to alleviate symptoms of caregiver burnout, such as poor sleep and frequent crying.

Choice A rationale

While constipation due to immobility can be a concern for a client diagnosed with Parkinson’s disease, it is not the highest priority. The nurse should ensure that the client has a diet high in fiber and drinks plenty of fluids to prevent constipation. Regular physical activity can also help to stimulate bowel movements. However, this is not the most critical issue that needs to be addressed.

Choice B rationale

The risk for aspiration due to muscle weakness is the highest priority for a client diagnosed with Parkinson’s disease. This is because Parkinson’s disease can cause difficulties with swallowing, which can lead to aspiration. Aspiration can lead to serious complications such as pneumonia. The nurse should monitor the client for signs of difficulty swallowing and aspiration. The client may need to be referred to a speech therapist for a swallowing evaluation and may need modifications to their diet to make swallowing easier.

Choice C rationale

While impaired physical mobility due to muscle rigidity can be a concern for a client diagnosed with Parkinson’s disease, it is not the highest priority. The nurse should encourage the client to engage in regular physical activity to help manage muscle rigidity. Physical therapy may also be beneficial. However, this is not the most critical issue that needs to be addressed.

Choice D rationale

While a self-care deficit due to motor disturbance can be a concern for a client diagnosed with Parkinson’s disease, it is not the highest priority. The nurse should assess the client’s ability to perform activities of daily living and provide assistance as needed. Occupational therapy may also be beneficial. However, this is not the most critical issue that needs to be addressed.