A patient with a history of adrenal insufficiency has been admitted to the intensive care unit due to an acute adrenal crisis.

The patient is experiencing nausea and joint pain.

The patient’s vital signs are as follows: temperature of 102 F (38.9° C), heart rate of 138 beats/minute, and blood pressure of 80/60 mm Hg. What is the first intervention the nurse should implement?

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.

1. Complete a focused assessment: The first step in managing a patient with abdominal pain and other symptoms is to perform a comprehensive assessment. This will help identify the cause of the symptoms and guide subsequent interventions.
2. Offer PRN pain medication: Once the immediate risks have been addressed, managing the patient’s pain is a priority. However, the choice of pain medication will depend on the results of the assessment.
3. Send the emesis sample to the lab: Sending the emesis sample to the lab can provide valuable information about the cause of the patient’s symptoms. However, this is not as urgent as the other interventions.
4. Elevate the head of the bed: Elevating the head of the bed can help reduce the risk of aspiration, especially in a patient who has vomited. This should be done as soon as possible.