A nurse is caring for a child who has Addison's disease.
Which of the following actions should the nurse take?
Discuss the manifestations of hyperglycemia with the parents.
Teach the parents about cortisol replacement therapy.
Place the child on a low-sodium diet.
Monitor the child for fluid volume excess.
The Correct Answer is B
Choice A rationale
Discussing hyperglycemia manifestations is not specific to Addison's disease, as Addison's is characterized by hypoglycemia due to cortisol deficiency.
Choice B rationale
Teaching the parents about cortisol replacement therapy is essential in Addison's disease management. Cortisol deficiency is the primary issue, so educating on proper administration and monitoring is crucial.
Choice C rationale
Placing the child on a low-sodium diet is not recommended because Addison's disease often involves salt wasting, so adequate sodium intake is necessary.
Choice D rationale
Monitoring for fluid volume excess is more applicable to conditions like heart failure, not Addison's disease, which is associated with dehydration and hypovolemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Temperature of 36.1°C (97.0°F) is below normal range and not indicative of organ rejection. Organ rejection often presents with elevated temperature due to the inflammatory response of the immune system attacking the transplanted organ.
Choice B rationale
Weight loss is not a common sign of acute organ rejection. Usually, fluid retention and associated weight gain can occur due to decreased kidney function.
Choice C rationale
Oliguria (reduced urine output) is a primary sign of kidney transplant rejection. It indicates that the transplanted kidney is not functioning properly, which is a critical indicator of rejection.
Choice D rationale
Insomnia is not typically associated with organ rejection. It can be related to stress or other factors but is not a direct sign of rejection.
Correct Answer is C
Explanation
Choice A rationale
Bubbling in the water seal chamber with exhalation indicates that air is still being removed from the pleural space, which is expected with a pneumothorax and is not a cause for immediate concern.
Choice B rationale
Eyelets not being visible indicate that the chest tube is properly placed within the pleural space, not an urgent issue.
Choice C rationale
Movement of the trachea towards the unaffected side is a sign of tension pneumothorax, which requires immediate intervention as it can compromise respiratory function.
Choice D rationale
Crepitus in the area above and surrounding the insertion site indicates subcutaneous emphysema, which can occur but does not necessitate immediate provider notification unless severe.
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