A client has an acute adrenal (addisonian) crisis. Which observation is the most significant during the nursing assessment?

Serum glucose 158 mg/dL (8.77 mmol/L)

Blood pressure 98/52 mm Hg

Weight gain 3 pounds (1.36 kg) in 24 hours

Insomnia and restlessness

Answer and Explanation

The Correct Answer is B

Choice A reason: Serum glucose 158 mg/dL (8.77 mmol/L) is not the most significant observation for an acute adrenal crisis, but a mild elevation of blood sugar. A mild elevation of blood sugar may occur due to stress, infection, medication, or diet, among other factors. It does not indicate a severe deficiency of adrenal hormones, which is the cause of an acute adrenal crisis.

Choice B reason: Blood pressure 98/52 mm Hg is the most significant observation for an acute adrenal crisis, as it indicates a condition called hypotension. Hypotension is a low blood pressure that may cause dizziness, fainting, shock, or organ failure. It is a sign of an acute adrenal crisis, which is a life-threatening emergency that occurs when the adrenal glands fail to produce enough cortisol and aldosterone. Cortisol and aldosterone are hormones that regulate blood pressure, blood sugar, and electrolyte balance.

Choice C reason: Weight gain 3 pounds (1.36 kg) in 24 hours is not the most significant observation for an acute adrenal crisis, but a possible sign of fluid retention. Fluid retention may occur due to heart failure, kidney disease, liver disease, or medication, among other causes. It does not indicate a severe deficiency of adrenal hormones, which is the cause of an acute adrenal crisis.

Choice D reason: Insomnia and restlessness are not the most significant observations for an acute adrenal crisis, but possible symptoms of anxiety, stress, or hyperthyroidism. Anxiety, stress, and hyperthyroidism may cause difficulty sleeping, nervousness, or agitation, among other effects. They do not indicate a severe deficiency of adrenal hormones, which is the cause of an acute adrenal crisis.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Liver failure is not the most common cause of this type of pain because it is a condition where the liver loses its ability to perform its vital functions, such as detoxifying the blood, producing bile, and metabolizing nutrients. Liver failure can cause symptoms such as jaundice, ascites, or bleeding, but it does not usually cause burning pain in the feet.

Choice B reason: Diabetes mellitus is the most common cause of this type of pain because it is a condition where the blood glucose level is too high, either due to insufficient insulin production or reduced insulin sensitivity. Diabetes mellitus can cause damage to the nerves, especially in the peripheral areas, such as the feet, which is called diabetic neuropathy. Diabetic neuropathy can cause symptoms such as burning pain, numbness, or tingling in the feet, which can worsen at night or with pressure.

Choice C reason: Mercury toxicity is not the most common cause of this type of pain because it is a condition where the body is exposed to high levels of mercury, which is a toxic metal that can be found in some fish, dental fillings, or thermometers. Mercury toxicity can cause damage to the nervous system, causing symptoms such as tremors, memory loss, or mood changes, but it does not usually cause burning pain in the feet.

Choice D reason: Vitamin B12 deficiency is not the most common cause of this type of pain because it is a condition where the body does not have enough vitamin B12, which is a nutrient that is essential for the production of red blood cells and the maintenance of the nervous system. Vitamin B12 deficiency can cause symptoms such as anemia, fatigue, or weakness, but it does not usually cause burning pain in the feet.

A. The thyroid gland is cancerous B. The client has a low serum calcium level C. The thyroid gland has been surgically removed D. The thyroid gland is enlarged

Correct Answer is D

Explanation

Choice A reason: The thyroid gland is cancerous is not a correct description of a goiter. A goiter is a non-specific term that refers to any enlargement of the thyroid gland, which may have various causes and may or may not be associated with thyroid cancer.

Choice B reason: The client has a low serum calcium level is not a correct description of a goiter. A low serum calcium level is a sign of hypoparathyroidism, which is a condition that affects the parathyroid glands, not the thyroid gland. The parathyroid glands are located behind the thyroid gland and regulate the calcium and phosphorus levels in the blood.

Choice C reason: The thyroid gland has been surgically removed is not a correct description of a goiter. A goiter is a condition that involves the presence of an enlarged thyroid gland, not the absence of it. A surgical removal of the thyroid gland is called a thyroidectomy, which may be done for various reasons such as thyroid cancer, hyperthyroidism, or large goiters.

Choice D reason: The thyroid gland is enlarged is the best description of a goiter. A goiter is a condition that involves the enlargement of the thyroid gland, which may be due to iodine deficiency, autoimmune disease, inflammation, infection, benign nodules, or thyroid hormone imbalance. A goiter may cause symptoms such as difficulty swallowing, breathing, or speaking, hoarseness, cough, or neck discomfort.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client has an acute adrenal (addisonian) crisis. Which observation is the most significant during the nursing assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse provides care for a client who reports burning pain, which is worse at night, in both feet. The client states the pressure of the sheets on the feet is "unbearable". Which reason is the most common cause of this type of pain?

Correct Answer is B

Explanation

During review of a client's history, the nurse notes that a goiter is present. Which statement best describes a goiter?

Correct Answer is D

Explanation

The nurse provides care for a client diagnosed with bronchitis. Which statement is most significant during the assessment of a client diagnosed with chronic bronchitis?

A previously healthy, young adult had cardiopulmonary arrest during a football game and died. The nurse knows which explanation is the most likely cause of death?

The nurse provides care for a client who has a history of renal calculi. Which type of renal calculi is most common in clients with gout?

The nurse provides care for a client with a 10-year history of Crohn's disease. Which finding best describes a common complication of Crohn's disease?

Which explanation does the nurse know best describes the role of inflammation in the development of atherosclerosis?

The nurse provides care for a client admitted one hour ago with the diagnosis of salicylate toxicity. The client has an arterial pH of 7.32. Which finding does the nurse expect to observe?

The nurse cares for a client with severe ascites due to alcoholic cirrhosis. Which description best explains the mechanism for ascites development in this client?

The nurse cares for the client with a history of pulmonary tuberculosis (TB). Two granulomas were present in the chest x-ray. Which explanation does the nurse understand best describes the primary immune response to tuberculosis infection?