In reviewing a 50-year-old client's medical record, which clinical manifestation should the nurse plan to assess for?

Mild headaches

Cloudiness that worsens at night

Severe eye pain

Mild eye pain

Answer and Explanation

The Correct Answer is C

Choice A reason: Mild headaches are not typically associated with increased intraocular pressure. While headaches can accompany eye conditions, they are not as common or specific as severe eye pain in this context.

Choice B reason: Cloudiness that worsens at night could be related to cataracts or other eye conditions but is not a specific manifestation of increased intraocular pressure. Severe eye pain is a more direct indicator of conditions like acute angle-closure glaucoma.

Choice C reason: Severe eye pain is a significant clinical manifestation of increased intraocular pressure, such as in acute angle-closure glaucoma. This condition can lead to sudden, severe eye pain due to the rapid rise in intraocular pressure, which can damage the optic nerve if not treated promptly.

Choice D reason: Mild eye pain may occur in various minor eye conditions but is not as indicative of serious issues like increased intraocular pressure. Severe eye pain is more concerning and requires immediate assessment and intervention.

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Correct Answer is C

Explanation

Choice A reason: Pyridostigmine is used to treat myasthenia gravis, not for preventing Addisonian crisis in patients undergoing adrenalectomy. It is not related to adrenal hormone replacement.

Choice B reason: Tensilon (edrophonium) is used in the diagnosis of myasthenia gravis and is not relevant for managing adrenal insufficiency or preventing Addisonian crisis.

Choice C reason: Hydrocortisone intravenously is the correct choice for preventing Addisonian crisis in a client scheduled for adrenalectomy. Hydrocortisone provides the necessary corticosteroid replacement to manage the deficiency of adrenal hormones during and after surgery.

Choice D reason: Spironolactone is a potassium-sparing diuretic used to treat conditions like heart failure and hypertension. It is not used for preventing Addisonian crisis or managing adrenal insufficiency.

A. Administer the prescribed antipyretic and notify the primary health care provider. B. Assess the color and content of the urine specimen for urinalysis. C. Note the consistency of respiratory secretions and obtain a specimen for culture. D. Compare all prior vital signs and continue to monitor every hour.

Correct Answer is A

Explanation

Choice A reason: Administering an antipyretic to reduce the fever and notifying the primary health care provider are the priority actions. A rapid rise in temperature in a client with multiple myeloma receiving chemotherapy could indicate a serious infection, which requires prompt medical attention.

Choice B reason: Assessing the color and content of the urine specimen for urinalysis is important but is not the immediate priority. The rapid rise in temperature is a more urgent concern.

Choice C reason: Noting the consistency of respiratory secretions and obtaining a specimen for culture is important but not the immediate priority. The primary concern is addressing the fever and notifying the healthcare provider.

Choice D reason: Comparing prior vital signs and continuing to monitor every hour is necessary but not the immediate priority. Immediate action is required to address the fever and potential infection.

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In reviewing a 50-year-old client's medical record, which clinical manifestation should the nurse plan to assess for?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is scheduled for an adrenalectomy. The nurse plans to administer which medication in the preoperative period to prevent Addisonian Crisis?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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