A nurse is caring for a client diagnosed with Addison's disease who is at risk for Addisonian crisis. The nurse is aware that which of the following is the priority assessment?

Monitor serum electrolytes

Monitor for signs of shock.

Monitor daily weights

Monitor Intake and output

Answer and Explanation

The Correct Answer is B

A. While monitoring serum electrolytes is important, it is secondary to assessing for immediate life-threatening conditions.
B. Monitoring for signs of shock is the priority, as Addisonian crisis can lead to severe hypotension and shock, which requires immediate intervention.
C. Monitoring daily weights can help assess fluid status but is not critical in the context of an impending crisis.
D. Monitoring intake and output is important for overall assessment but does not directly address the immediate risks associated with Addisonian crisis.

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Correct Answer is C

Explanation

A. Diplopia is a concerning symptom but does not indicate immediate deterioration in neurological status like a change in GCS does.
B. Ataxia is also significant but is less acute than a drop in GCS score.
C. A change in the Glasgow Coma Scale score from 13 to 11 indicates a worsening level of consciousness and necessitates immediate reporting, as it may suggest increased intracranial pressure or other complications.
D. A decrease in heart rate from 76 to 69 bpm is not significant enough in the context of TBI to warrant immediate reporting, as it remains within a normal range.

A. Place the client in a supine position. B. Instruct client to pull self up in bed C. Use log rolling to reposition the client. D. Assist client to sit with legs dangling

Correct Answer is C

Explanation

A. The supine position can increase ICP and is not recommended for clients with elevated ICP.
B. Instructing the client to pull themselves up may increase ICP due to straining.
C. Log rolling helps maintain spinal alignment and minimizes abrupt head movement, which is essential in managing ICP.
D. Sitting with legs dangling may cause a sudden shift in intracranial pressure and is not advised for these clients.

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A nurse is caring for a client diagnosed with Addison's disease who is at risk for Addisonian crisis. The nurse is aware that which of the following is the priority assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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