What is the priority nursing assessment for a client diagnosed with acute adrenal insufficiency (adrenal crisis)? Assessing...
respiratory rate
cranial nerves
blood glucose levels
range of motion
The Correct Answer is A
A. Respiratory rate is correct. In acute adrenal insufficiency (also known as adrenal crisis), there is a severe deficiency of cortisol, which can lead to hypotension, shock, and respiratory distress. Assessing the respiratory rate is crucial to identify any signs of respiratory compromise or distress, which can occur in adrenal crisis due to circulatory and metabolic instability.
B. Cranial nerves is incorrect. While cranial nerve assessment is important in neurological evaluations, it is not the priority assessment for acute adrenal insufficiency. Respiratory and circulatory assessments take precedence in this emergency situation.
C. Blood glucose levels is incorrect. While blood glucose levels should be monitored in adrenal crisis (due to potential hypoglycemia), the priority assessment is focused on respiratory function and signs of shock, as these are the most immediate threats to the client's life.
D. Range of motion is incorrect. While it’s important to assess mobility in general nursing care, assessing the range of motion is not a priority in acute adrenal insufficiency, where immediate concerns are more related to respiratory status and hemodynamic stability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
A. Perioperative antibiotics is correct. The benchmark is 100%. Performance was 90.4% in Q1, 88.2% in Q2, and 92.6% in Q3, all of which are below the benchmark, indicating noncompliance.
B. Smoking cessation is correct. The benchmark is 75%. While Q2 reached 100%, Q1 (70.6%) and Q3 (74%) were both below the benchmark, showing inconsistent compliance.
C. Glucose control is correct. The benchmark is 90%. All quarters were below the benchmark: Q1 (75.2%), Q2 (85.5%), and Q3 (82%).
D. Post operative normothermia is correct. The benchmark is 85%. Q1 (69%) fell below the benchmark, although Q2 and Q3 met or exceeded it. Still, any quarter below the benchmark signals an area for improvement.
E. Intraoperative vancomycin is incorrect. The benchmark is 80.2%. While Q1 (75.7%) fell slightly below the benchmark, Q2 (80.5%) and Q3 (92%) met or exceeded it, indicating overall adequate performance and improvement over time.
Correct Answer is D
Explanation
A. Administer an oral potassium supplement is incorrect. Potassium imbalances can cause muscle weakness and cramps, but the client’s symptoms are more likely related to hypocalcemia rather than hypokalemia. Administering potassium without verifying the actual cause of the symptoms could be inappropriate.
B. Request prescription for a relaxant is incorrect. While muscle spasms can be painful, the first priority is to address the underlying cause of the spasms, which in this case is likely hypocalcemia. A muscle relaxant might not address the root cause and could delay appropriate treatment.
C. Check the pedal pulses is incorrect. While checking pedal pulses is important for assessing circulation, the client's symptoms of severe muscle spasms are more indicative of hypocalcemia rather than a circulation issue. The nurse's priority should be to address the electrolyte imbalance.
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