The nurse is caring for a patient with Addison's disease in the emergency department.
The patient states that they were out in the sun gardening all day and is now lethargic, forgetful, and has a temperature of 101.5°F. What intervention will the nurse prioritize when caring for this patient?
Administer intravenous fluids with glucose.
Administer 1000 mg of acetaminophen orally.
Educate the patient about ordered hydrocortisone.
Explore options to minimize stress.
The Correct Answer is A
Choice A rationale
Administering intravenous fluids with glucose is essential for a patient with Addison's disease who has been exposed to stressors like prolonged sun exposure. Patients with Addison's disease may experience an adrenal crisis, characterized by low blood pressure, dehydration, and hypoglycemia. Intravenous fluids with glucose help to rehydrate the patient and restore blood sugar levels, which are critical in preventing shock and other severe complications.
Choice B rationale
Administering 1000 mg of acetaminophen orally is not the priority intervention for this patient. While it may help reduce fever, it does not address the underlying issues of Addison's disease, such as hypoglycemia and dehydration, which are more urgent. The primary concern should be stabilizing the patient's vital signs and electrolyte balance.
Choice C rationale
Educating the patient about ordered hydrocortisone is important for long-term management of Addison's disease, but it is not the immediate priority in an emergency situation. The patient requires prompt medical intervention to address the acute symptoms of adrenal insufficiency, such as lethargy and hypoglycemia.
Choice D rationale
Exploring options to minimize stress is relevant for managing Addison's disease in general, as stress can trigger an adrenal crisis. However, in the emergency department, the nurse's priority should be to stabilize the patient and manage acute symptoms. Stress management can be addressed once the patient's condition is stabilized.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Referring the patient to a psychiatrist for anti-depressant medications may not address the immediate issue of fatigue and breathlessness related to acute leukemia. While psychological support is important, the primary focus should be on managing the patient's physical symptoms and improving oxygenation during activities.
Choice B rationale
Providing portable oxygen therapy via nasal cannula during physical activity is the best intervention for this patient. Oxygen therapy can help alleviate the patient's symptoms of breathlessness and fatigue by ensuring adequate oxygen levels during physical exertion. This intervention allows the patient to engage in activities with less discomfort and prevents further complications related to hypoxia.
Choice C rationale
Instructing the patient to increase their oral iron supplement dose until fatigue subsides is not appropriate without medical supervision. Iron supplementation should be based on the patient's iron levels and hematologic status. Over-supplementation can lead to adverse effects and may not address the underlying cause of fatigue in patients with acute leukemia.
Choice D rationale
Encouraging the patient to perform light exercises daily can be beneficial for overall health, but it may not be practical for someone experiencing severe fatigue and breathlessness. The patient's immediate need for oxygen support during activities takes precedence, and physical activity should be tailored to their current capabilities and medical condition. .
Correct Answer is C
Explanation
Choice A rationale
Placing the patient in a private, lead-lined room is unnecessary for external radiation therapy, which does not make the patient radioactive. This consideration is more applicable to internal radiation therapy (brachytherapy), where radioactive materials are placed inside the body.
Choice B rationale
While dosimeter badges are essential for monitoring radiation exposure, they are more relevant for healthcare workers who may be exposed to radiation, not for patients receiving external radiation therapy. The patient themselves are not a source of radiation exposure.
Choice C rationale
Monitoring the patient's skin integrity is crucial because external radiation can cause skin irritation and damage. Avoiding exposure to extreme heat or cold helps prevent additional skin trauma and promotes healing.
Choice D rationale
Restricting visitors and posting radioactive precautions signs are unnecessary for patients receiving external radiation therapy. These precautions are more applicable to internal radiation therapy, where the patient may emit radiation.
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