A patient diagnosed with hyperaldosteronism presents with symptoms of a blood pressure of 220/135 mmHg and a potassium level of 3.1 mEq/L. Which of the following interventions should the nurse prioritize?
Schedule the patient for a CT scan of the adrenal glands.
Initiate a low-sodium diet as the first intervention.
Monitor the patient for signs of fluid overload.
Administer potassium supplements to correct hypokalemia.
The Correct Answer is C
Choice A rationale
Scheduling a CT scan is a diagnostic step used to identify adrenal adenomas or hyperplasia, which are common causes of primary hyperaldosteronism. However, in an acute presentation with a blood pressure of 220/135 mmHg, diagnostic imaging is not the immediate priority. The patient is experiencing a hypertensive crisis, which requires urgent physiological stabilization. While imaging is necessary for long-term treatment planning, the nurse must first address the life-threatening hemodynamic instability and electrolyte imbalances to prevent end-organ damage.
Choice B rationale
A low-sodium diet is a long-term management strategy for hyperaldosteronism to help control fluid retention and hypertension. However, in the presence of a hypertensive emergency, dietary modifications are insufficient and too slow to be effective. The patient requires immediate pharmacological intervention to lower blood pressure and prevent a cerebrovascular accident or myocardial infarction. Initial nursing actions must focus on acute interventions that produce rapid physiological changes rather than lifestyle or dietary adjustments that take days to manifest.
Choice C rationale
Monitoring for signs of fluid overload is the priority because aldosterone causes the kidneys to retain sodium and water while excreting potassium. Excess aldosterone leads to an expanded intravascular volume, contributing to the severe hypertension of 220/135 mmHg. The nurse must assess for peripheral edema, jugular venous distention, and pulmonary crackles. Managing volume status is critical to preventing heart failure and further escalation of the hypertensive crisis, making it the most vital assessment for a patient in this state.
Choice D rationale
Administering potassium supplements is necessary to correct the hypokalemia of 3.1 mEq/L, as the normal range is 3.5 to 5.0 mEq/L. However, potassium must be replaced with extreme caution in the setting of severe hypertension and potential renal impairment. While correcting the heart's electrical stability is important, the immediate threat to the patient's life is the extremely high blood pressure. Monitoring the systemic effects of the fluid and electrolyte imbalance takes precedence to guide safe administration of intravenous medications. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","F"]
Explanation
Choice A rationale
Chronic conditions such as cardiovascular disease or diabetes mellitus can significantly impair the body's ability to circulate blood to the skin for heat dissipation. Furthermore, specific medications including diuretics, antihistamines, and beta-blockers interfere with sweating mechanisms or cardiac output. This disruption in homeostatic thermoregulation prevents the hypothalamus from effectively lowering the core body temperature during periods of high thermal stress, thereby increasing the clinical susceptibility to heat-related illnesses.
Choice B rationale
Aging is associated with physiological changes that decrease the efficiency of the thermoregulatory system, including a reduced number of active sweat glands and decreased dermal blood flow. The loss of subcutaneous fat in older adults may paradoxically impair the body's insulation and its ability to regulate temperature fluctuations. Consequently, the elderly population cannot dissipate heat as rapidly as younger individuals, which raises the risk of progressing from heat exhaustion to life-threatening heat stroke.
Choice C rationale
Dehydration significantly reduces the total circulating blood volume, which is essential for transporting heat from the internal organs to the skin surface. When fluid intake is insufficient, the body prioritizes maintaining blood pressure over thermoregulation, leading to a cessation of sweating to conserve water. Without the evaporative cooling provided by sweat, the core body temperature rises uncontrollably. Normal adult fluid requirements are approximately 2000 to 3000 mL daily to maintain adequate hydration.
Choice D rationale
Performing regular physical activity within a moderate, climate-controlled environment does not typically pose a significant threat to the body's thermoregulatory capacity. In these conditions, the ambient temperature gradient allows for efficient heat loss through radiation and convection. Since the environmental stress is low, the physiological mechanisms for cooling remain functional and are not overwhelmed. Therefore, this factor does not contribute to the onset of heat exhaustion or heat stroke in most healthy or stable patients.
Choice E rationale
A sedentary lifestyle in a cold environment is generally associated with risks related to hypothermia or frostbite rather than heat-related emergencies. Heat stroke requires high external temperatures or extreme internal metabolic heat production that exceeds the body's ability to cool itself. Cold exposure causes peripheral vasoconstriction to conserve heat, which is the opposite physiological process of what occurs during heat exhaustion. Consequently, these specific conditions do not facilitate the development of hyperthermic syndromes.
Choice F rationale
High ambient temperatures combined with elevated humidity create a dangerous environment because the air is saturated with moisture, preventing the evaporation of sweat. Evaporation is the primary mechanism for heat loss in humans when the environment is warmer than the skin. When sweat cannot evaporate, the body's most effective cooling tool is neutralized. This leads to a rapid accumulation of metabolic and environmental heat within the tissues, causing systemic cellular dysfunction and potential multi-organ failure.
Choice G rationale
Wearing loose-fitting and lightweight clothing is a protective measure rather than a risk factor. Such attire allows for maximum airflow over the skin surface, which facilitates the evaporation of perspiration and the convective loss of heat. Tight or heavy clothing traps heat and moisture against the body, creating a microenvironment that hinders cooling. By promoting ventilation, lightweight clothing assists the body in maintaining a stable internal temperature even when exposed to moderately high external heat.
Correct Answer is B
Explanation
Choice A rationale
Elevated blood glucose and increased appetite are side effects of chronic glucocorticoid therapy rather than signs of acute adrenal insufficiency. Cortisol normally stimulates gluconeogenesis and antagonizes insulin; therefore, an excess causes hyperglycemia. In acute insufficiency, the opposite occurs: glucose levels typically drop below 70 mg/dL because there is insufficient cortisol to maintain carbohydrate metabolism. Increased appetite is a classic sign of Cushing's syndrome or steroid-induced polyphagia, not an acute adrenal crisis.
Choice B rationale
Fatigue, weakness, and dizziness are early clinical manifestations of an addisonian crisis resulting from severe cortisol and aldosterone depletion. These symptoms occur due to a combination of hypoglycemia and decreased cardiac output. As fluid volume decreases and blood pressure drops, the brain and muscles receive inadequate perfusion, leading to profound lethargy. Monitoring for these signs is vital when a patient begins hydrocortisone, as it may indicate that the dosage is insufficient to meet the body's metabolic demands.
Choice C rationale
Increased blood pressure and tachycardia are not typical of acute adrenal insufficiency; rather, hypotension is the hallmark sign. While tachycardia can occur as a compensatory mechanism for low stroke volume, the lack of mineralocorticoids usually prevents the body from maintaining a high blood pressure. In a crisis, the systolic blood pressure often falls below 90 mmHg. If a patient displays hypertension, it is more likely an indication of over-replacement of steroids or another unrelated cardiovascular condition.
Choice D rationale
Fluid retention and hypertension are symptoms of mineralocorticoid excess, often seen in conditions like primary aldosteronism or as a side effect of excessive hydrocortisone administration. Acute adrenal insufficiency is characterized by the massive loss of water and sodium through the kidneys, leading to profound hypovolemia and vascular collapse. Normal blood pressure is roughly 120/80 mmHg; in insufficiency, these values decrease significantly. Therefore, the nurse should be looking for signs of dehydration and low blood pressure instead. .
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