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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Low-income individuals may qualify for Medicaid, not Medicare. Medicaid is a state and federally funded program designed for individuals with limited income and resources.
B. Military veterans typically receive health benefits through the VA (Veterans Affairs) system, not Medicare, unless they meet other eligibility criteria (like age).
C. Individuals aged 55–64 are not automatically eligible for Medicare unless they have certain qualifying disabilities or end-stage renal disease.
D. Individuals aged 65 and older are eligible for Medicare. Medicare is a federal health insurance program primarily for people aged 65 and over, though some younger individuals with disabilities may also qualify.

A. Bed sheet B. Patient gown C. Beige jacket D. Blow dryer

Correct Answer is C

Explanation

A. Bed sheet is a common item considered a safety risk in real clinical settings, but in this specific safety exercise, it was not the item identified as being on the back of the chair.
B. Patient gown is typically worn by the client and would not usually be placed on the back of a chair as a risk item during a safety evaluation.
C. Beige jacket is correct. In the safety exercise scenario, the beige jacket was on the back of the chair, and it could pose a ligature risk, making it a key item of concern in suicide prevention protocols.
D. Blow dryer may be a potential safety risk in general, but it was not the item noted on the back of the chair in the described scenario.

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What is the priority nursing assessment for a client diagnosed with acute adrenal insufficiency (adrenal crisis)? Assessing...

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