Which of the following would be the most appropriate nursing diagnosis for a client admitted with Addison's disease?
Impaired skin integrity
Fluid volume overload
Imbalanced nutrition: more than body requirements
Risk for injury
The Correct Answer is D
Choice A Reason: Impaired skin integrity is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and cortisol deficiency.
Choice B Reason: Fluid volume overload is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and aldosterone deficiency.
Choice C Reason: Imbalanced nutrition: more than body requirements is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and weight loss.
Choice D Reason: Risk for injury is the most appropriate nursing diagnosis for a client with Addison's disease, as it reflects the main problem of adrenal insufficiency and hypotension, which can cause falls, fainting, or shock.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Compressing the nares is not the first action that the nurse should take, as it may increase intracranial pressure and worsen the head injury.
Choice B Reason: Administering decongestant for postnasal drip is not the first action that the nurse should take, as it may mask the signs of cerebrospinal fluid (CSF) leakage and delay diagnosis and treatment.
Choice C Reason: Tilting the head back is not the first action that the nurse should take, as it may cause aspiration of CSF or blood and increase the risk of infection.
Choice D Reason: Collecting the drainage is the first action that the nurse should take, as it helps to identify if the drainage is CSF or nasal secretions, and to monitor the amount and characteristics of the drainage.
Correct Answer is D
Explanation
Choice A Reason: Parkinson's disease does not result from too low acetylcholine as a result of an autoimmune reaction, but this may be a description of myasthenia gravis, which affects the neuromuscular junction.
Choice B Reason: Parkinson's disease is not caused by the deterioration of the myelin sheath of the basal ganglia, but this may be a description of multiple sclerosis, which affects the central nervous system.
Choice C Reason: Excess dopamine and deficient acetylcholine are not the two major causes of Parkinson's disease, but they are reversed. Parkinson's disease is caused by low dopamine and high acetylcholine levels in the brain.
Choice D Reason: Parkinson's is caused by depletion of dopamine and excess of acetylcholine, as this affects the balance between these two neurotransmitters that control movement and coordination.
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