Which of the following assessment findings indicates an emergency and the need for immediate action on the part of the nurse?

Clubbing of the fingernails

Tracheal deviation

Contraction of the diaphragm

Auscultation of rhonchi throughout the lungs

Answer and Explanation

The Correct Answer is B

A. Clubbing of the fingernails is typically a sign of chronic hypoxia and is seen in conditions like cystic fibrosis, COPD, and other respiratory or cardiovascular diseases. It is a long-term issue and does not indicate an immediate emergency.
B. Tracheal deviation is a medical emergency and typically indicates tension pneumothorax, where air accumulates in the pleural space, shifting the trachea away from the affected side. This can compress the heart and lungs, leading to respiratory and circulatory collapse, requiring immediate action.
C. Contraction of the diaphragm may refer to normal breathing mechanics and does not indicate an immediate emergency unless it is associated with respiratory distress or failure.
D. Rhonchi are abnormal lung sounds often associated with mucus in the airways and can be heard in conditions like bronchitis or COPD. Although they may require attention, they do not represent an immediate emergency compared to tracheal deviation.

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Correct Answer is B

Explanation

A. While avoiding infection is important for individuals with Addison's disease due to their weakened immune system, the priority is ensuring proper medication management.
B. Managing lifelong corticosteroid replacement is the most crucial instruction because individuals with Addison's disease have insufficient production of adrenal hormones, particularly cortisol. Without appropriate corticosteroid therapy, they can experience life-threatening adrenal crises.
C. Wearing a Medic-Alert bracelet is a helpful precaution, but it is not as immediately critical as ensuring proper medication management.
D. Practicing stress-management techniques is beneficial, as stress can exacerbate symptoms of Addison's disease, but corticosteroid replacement remains the highest priority.

A. "It is caused by the lack of production of insulin by the pancreas." B. "It is caused by the overproduction of parathormone by the parathyroid gland." C. "It is caused by the lack of production of aldosterone by the adrenal gland." D. "It is caused by the overproduction of growth hormone by the pituitary gland."

Correct Answer is C

Explanation

A. "It is caused by the lack of production of insulin by the pancreas.": This is incorrect. The lack of insulin production causes diabetes mellitus, not Addison’s disease. Addison’s disease results from insufficient production of adrenal hormones, particularly aldosterone and cortisol.
B. "It is caused by the overproduction of parathormone by the parathyroid gland.": This is incorrect. Parathormone is produced by the parathyroid glands and regulates calcium balance, but overproduction of parathormone leads to conditions such as hyperparathyroidism, not Addison’s disease.
C. "It is caused by the lack of production of aldosterone by the adrenal gland.": This is correct. Addison’s disease, also known as primary adrenal insufficiency, is caused by the inability of the adrenal glands to produce sufficient aldosterone and cortisol, two critical hormones. Aldosterone helps regulate sodium and potassium balance, and cortisol helps the body respond to stress.
D. "It is caused by the overproduction of growth hormone by the pituitary gland.": This is incorrect. Overproduction of growth hormone causes acromegaly or gigantism, not Addison’s disease. Addison’s disease results from adrenal insufficiency, not pituitary gland dysfunction.

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Which of the following assessment findings indicates an emergency and the need for immediate action on the part of the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which instruction is highest priority when the nurse is developing a teaching plan for a patient with Addison's disease?

Correct Answer is B

Explanation

A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions?

A nurse is assessing a client who is admitted for elective surgery and has a history of Addison's disease. Which of the following findings should the nurse expect?

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A patient's status post hypophysectomy had drainage on the mustache dressing. Which complication is this patient at risk for if the glucose level of the drainage is 50 mg/dL?

A nurse is caring for a client who is being evaluated for acromegaly. Which of the following manifestations should the nurse expect to find during assessment? (Select all that apply.)

The nurse suspects which cause of increased bubbling in the water seal chamber of a patient's chest drainage unit?

A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect?