A patient with pheochromocytoma
is admitted to the hospital with severe hypertension. Which nursing intervention is the highest priority?
Administering an alpha-adrenergic blocker as prescribed.
Administering intravenous fluids to maintain hydration.
Monitoring blood glucose levels every 4 hours.
Preparing the patient for immediate surgery to remove the tumor.
The Correct Answer is A
Choice A Reason:
Administering an alpha-adrenergic blocker is the highest priority intervention for a patient with pheochromocytoma and severe hypertension. Pheochromocytoma causes excessive secretion of catecholamines, leading to severe hypertension. Alpha-adrenergic blockers help to control blood pressure by blocking the effects of these catecholamines, thereby reducing vasoconstriction and lowering blood pressure. This intervention is crucial to prevent hypertensive crises and associated complications such as stroke or myocardial infarction.
Choice B Reason:
Administering intravenous fluids to maintain hydration is important but not the highest priority. While maintaining hydration is essential, it does not directly address the severe hypertension caused by pheochromocytoma. Intravenous fluids can help support overall patient stability but do not specifically target the underlying cause of the hypertension.
Choice C Reason:
Monitoring blood glucose levels every 4 hours is a necessary intervention, especially since pheochromocytoma can cause hyperglycemia due to increased catecholamine levels. However, this intervention is not the highest priority compared to controlling the severe hypertension, which poses a more immediate threat to the patient’s health.
Choice D Reason:
Preparing the patient for immediate surgery to remove the tumor is a critical step in the long-term management of pheochromocytoma. However, surgery is not typically performed until the patient’s blood pressure is stabilized with medications such as alpha-adrenergic blockers. Therefore, while surgery is essential, it is not the immediate priority in the acute management of severe hypertension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A Reason:
Encouraging a high-sodium diet is essential for patients with Addison’s disease because they often suffer from hyponatremia (low sodium levels) due to the lack of aldosterone, a hormone that helps regulate sodium and potassium balance. Increasing sodium intake helps to counteract this deficiency and maintain proper electrolyte balance.
Choice B Reason:
Administering potassium supplements is not recommended for patients with Addison’s disease because they already have hyperkalemia (high potassium levels) due to the lack of aldosterone. Adding more potassium could exacerbate this condition and lead to serious complications such as cardiac arrhythmias.
Choice C Reason:
Administering intravenous corticosteroids is a critical intervention for managing Addison’s disease, especially during an adrenal crisis. Corticosteroids like hydrocortisone help replace the deficient hormones and stabilize the patient’s condition by reducing inflammation and supporting metabolic functions.
Choice D Reason:
Monitoring blood glucose levels regularly is important because patients with Addison’s disease can experience hypoglycemia (low blood sugar levels) due to cortisol deficiency. Regular monitoring helps in timely detection and management of hypoglycemia, preventing potential complications.
Choice E Reason:
Administering diuretics is not appropriate for patients with Addison’s disease as it can lead to further electrolyte imbalances, particularly worsening hyponatremia and hyperkalemia. Diuretics increase the excretion of sodium and potassium, which is counterproductive in managing Addison’s disease.
Correct Answer is ["B","C","D","F"]
Explanation
Choice A Reason:
Acetone breath is typically associated with diabetic ketoacidosis (DKA), not hyperosmolar hyperglycemic syndrome (HHS). DKA occurs when there is a significant production of ketones due to the breakdown of fat for energy, leading to a fruity or acetone-like smell on the breath. HHS, on the other hand, does not usually involve significant ketone production.
Choice B Reason:
Fever can be a manifestation of HHS, especially if there is an underlying infection or illness that has precipitated the hyperglycemic crisis. Infections are common triggers for HHS and can contribute to the severity of the condition.
Choice C Reason:
Older age is a risk factor for HHS. HHS is more commonly seen in older adults with type 2 diabetes, often those who have underlying chronic conditions or are experiencing acute illness. The patient’s age of 68 years supports the likelihood of HHS.
Choice D Reason:
A serum glucose level of 800 mg/dL is indicative of HHS. HHS is characterized by extremely high blood glucose levels, often exceeding 600 mg/dL, without significant ketone production. This high glucose level leads to severe dehydration and hyperosmolarity.
Choice E Reason:
A serum bicarbonate level of 15 mEq/L is more indicative of DKA rather than HHS. In HHS, serum bicarbonate levels are typically normal or only mildly decreased because there is no significant ketoacidosis. Therefore, this choice does not support the clinical presentation of HHS.
Choice F Reason:
An insidious onset is characteristic of HHS. Unlike DKA, which can develop rapidly, HHS often develops over days to weeks. Patients may experience gradually worsening symptoms such as increased thirst, frequent urination, and confusion before seeking medical attention.
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