A 46-year-old female patient presents to the emergency department with acute adrenal insufficiency and the following vital signs: P 118 beats/min, R 18 breaths/min, BP 83/44 mm Hg. pulse oximetry 98%. and T 98.8 F oral.
Which nursing intervention is the highest priority for this patient?
Administering furosemide (Lasix)
Replacing potassium losses
Providing isotonic fluids
Restricting sodium.
The Correct Answer is C
The patient's vital signs suggest that she is experiencing hypotension, tachycardia, and possibly dehydration due to acute adrenal insufficiency. The highest priority nursing intervention for this patient is to provide isotonic fluids to restore intravascular volume and blood pressure. This will also help to correct any electrolyte imbalances that may be present. Administering furosemide (Lasix) or replacing potassium losses may be necessary interventions, but they are not the highest priority at this time. Restricting sodium would be contraindicated in this situation as the patient is hypotensive and needs fluids to increase intravascular volume.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Diabetes insipidus is a condition in which the body is unable to properly regulate fluid balance, leading to excessive urination (polyuria) and thirst. Therefore, the nurse should anticipate the clinical manifestation of polyuria in a patient admitted to the hospital with diabetes insipidus. The patient may excrete large amounts of dilute urine, which can lead to dehydration if adequate fluid replacement is not provided. The other options listed (fluid volume overload, decreased gas exchange, and generalized edema) are not typically associated with diabetes insipidus, as this condition is characterized by a deficiency of antidiuretic hormone (ADH) rather than an excess of fluid.
Correct Answer is D
Explanation
Cushing syndrome is caused by excessive cortisol production by the adrenal glands, which can result in weight gain and redistribution of fat to the abdomen, giving it a characteristic rounded appearance.
The other options mentioned in the question are not typically associated with Cushing syndrome. Chronically low blood pressure is not typically seen in Cushing syndrome, as cortisol is a hormone that can raise blood pressure. A bronzed appearance of the skin is more commonly seen in conditions like Addison's disease, where there is a deficiency of cortisol. Decreased axillary and pubic hair is not a common finding in Cushing syndrome, although excessive hair growth (hirsutism) may occur due to the excess of androgens produced by the adrenal glands.
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