A patient with known adrenal insufficiency presents with hypotension, hyponatremia, and hyperkalemia.
What is the priority intervention?
Restrict fluids.
Provide potassium supplements.
Administer insulin.
Administer IV hydrocortisone.
The Correct Answer is D
Choice A rationale
Restricting fluids would be contraindicated in a patient with adrenal insufficiency experiencing hypotension. These patients suffer from a profound deficit of mineralocorticoids, specifically aldosterone, which leads to massive urinary loss of sodium and water. Normal serum sodium is 135 to 145 mEq/L. The resulting hypovolemia requires aggressive fluid resuscitation with isotonic saline to restore circulating volume and blood pressure. Fluid restriction would worsen the cardiovascular collapse and exacerbate the Addisonian crisis.
Choice B rationale
Providing potassium supplements is dangerous because hyperkalemia is already present in adrenal insufficiency. Normal serum potassium is 3.5 to 5.0 mEq/L. Without aldosterone, the kidneys cannot effectively excrete potassium in exchange for sodium. Adding more potassium would increase the risk of life threatening cardiac arrhythmias or cardiac arrest. The clinical goal is to lower the potassium levels through volume expansion and corticosteroid replacement rather than increasing the total body potassium load.
Choice C rationale
Administering insulin is a temporary measure used to shift potassium from the extracellular fluid into the intracellular compartment. While it addresses the hyperkalemia, it does not treat the underlying cause of the crisis, which is a lack of cortisol and aldosterone. Furthermore, patients in adrenal crisis are often hypoglycemic due to glucocorticoid deficiency. Giving insulin without dextrose could cause fatal hypoglycemia. It is not the primary priority compared to replacing the missing hormones.
Choice D rationale
Administering intravenous hydrocortisone is the priority intervention because it provides both glucocorticoid and mineralocorticoid activity. This replacement therapy addresses the underlying hormonal deficit, helping to restore vascular tone, increase blood glucose levels, and promote the renal retention of sodium and excretion of potassium. By correcting the hormonal imbalance, hydrocortisone stabilizes the hemodynamics and electrolyte disturbances. This intervention is essential to reverse the life threatening systemic effects of an acute adrenal or Addisonian crisis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["3"]
Explanation
58 Step 1 is 375 mg ÷ 125 mg. The final calculated answer is 3 tablets.
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale
Apoptosis is the process of programmed cell death used to remove damaged cells without causing an inflammatory response. In this clinical scenario, the client is exhibiting signs of an active, escalating infection and systemic inflammation rather than a controlled apoptotic process. The presence of a high white blood cell count of 16,200/mm and 10 percent bands suggests an acute shift toward necrosis and systemic activation rather than localized apoptotic pathways intended to limit damage.
Choice B rationale
Systemic inflammatory response syndrome involves the massive release of cytokines like tumor necrosis factor and interleukins into the bloodstream. These mediators cause widespread peripheral vasodilation to increase blood flow to tissues, but this results in a drop in blood pressure. The normal blood pressure varies, but a downward trend from a baseline of 120/80 mmHg toward hypotension indicates that these systemic cytokines are causing vascular relaxation and a significant decrease in systemic vascular resistance.
Choice C rationale
Inflammatory mediators increase the size of the gaps between endothelial cells in the capillaries. This allows protein-rich fluid to leak from the intravascular space into the interstitial space, known as third spacing. This process reduces the effective circulating blood volume, contributing to the client's declining blood pressure and localized edema. Normal capillary function maintains fluid balance, but during systemic inflammation, this permeability becomes global, leading to potential organ dysfunction and further hemodynamic instability in the client.
Choice D rationale
In the early stages of systemic inflammation and distributive shock, the systemic vascular resistance actually decreases due to vasodilation. The body typically attempts to compensate by increasing cardiac output via an increased heart rate to maintain perfusion. A decrease in cardiac output usually occurs later if the heart muscle becomes depressed by inflammatory toxins. The current assessment of trending down blood pressure is primarily driven by low resistance and fluid loss, not by an increase in resistance.
Choice E rationale
Neutrophils are the first responders to bacterial invasion and puncture wounds. They migrate to the injury site through chemotaxis and undergo degranulation to release antimicrobial enzymes. The client's white blood cell count of 16,200/mm is above the normal range of 5,000 to 10,000/mm, and the 10 percent bands indicate a left shift. This signifies that the bone marrow is releasing immature neutrophils to keep up with the significant demand of the escalating infection. .
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