A client is admitted for treatment of Addison's crisis. Which finding is most important for the practical nurse (PN) to report to the charge nurse? Reference Range: Glucose [Reference Range: 0 to 50 years: less than 140 mg/dL or less than 7.8 mmol/L].

The client reports feeling nauseous.

Has not voided in four hours.

IV infusion site is infiltrated

Serum glucose level of 85 mg/dL.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C - IV infusion site is infiltrated. Choice A rationale:

The client reports feeling nauseous. While this symptom should be monitored, it is not the most crucial finding to report for a client in Addison's crisis. Nausea can be a common symptom during various medical conditions and may not warrant immediate action.

Choice B rationale:

Has not voided in four hours. While monitoring urine output is important, it may not be the most critical finding in Addison's crisis. Other symptoms like electrolyte imbalances and

circulatory collapse is more concerning in this scenario.

Choice C rationale:

IV infusion site is infiltrated. In Addison's crisis, the client's condition may be precarious, and any complications with IV therapy could worsen the situation. It is essential to report this finding promptly to prevent further complications.

Choice D rationale:

A serum glucose level of 85 mg/dL. While monitoring glucose levels is essential in many situations, a glucose level of 85 mg/dL is within the reference range, which means it is not the most critical finding in Addison's crisis.

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Correct Answer is A

Explanation

The correct answer is Choice A:

"Are you planning to obey the voices?.”. Choice A rationale:

The PN should ask the client if he plans to obey the voices because it helps assess the potential risk of harm to himself or others. If the client indicates an intention to follow the voices' commands to harm someone, it indicates a serious concern for safety and may require immediate intervention to protect the client and others.

Choice B rationale:

While asking if the client believes the voices are real is important for understanding the client's perception of the situation, it may not immediately address the risk of harm that the client or others might be facing.

Choice C rationale:

Asking if the client has taken any hallucinogens is relevant to explore possible substance- induced psychosis, but this question should be asked later in the assessment process. The priority is to assess immediate safety concerns related to the client's compliance with the voices' instructions.

Choice D rationale:

Inquiring about when the voices began is important, but it is not the most urgent question in this situation. Although the onset of the symptoms is relevant, addressing the potential for harmful actions should be prioritized.

A. Dim the lights in the room and close the door. B. Guide the client through slow, rhythmic breathing. C. Turn the television on to the client's favorite show. D. Obtain a prescription for a higher dose of pain medication.

Correct Answer is B

Explanation

This is the best action for the PN to use in assisting this client to deal with his pain because it provides a non- pharmacological method of pain relief that can enhance the eﬀect of the opioid analgesic. Slow, rhythmic breathing can help the client relax, distract from the pain, and increase oxygenation and blood ﬂow.

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A client is admitted for treatment of Addison's crisis. Which finding is most important for the practical nurse (PN) to report to the charge nurse? Reference Range: Glucose [Reference Range: 0 to 50 years: less than 140 mg/dL or less than 7.8 mmol/L].

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A male college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The client tells the practical nurse (PN) that the voices are saying, "Kill, kill.”. Which question should the PN ask the client next?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

The practical nurse (PN) is reviewing a client's recent ophthalmic screening test results. Findings of optic neuropathy, loss of peripheral vision, and increased intraocular pressure are consistent with which medical condition?

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The practical nurse (PN) reviews the history of an older adult who is newly admitted to a long term care facility. Which factor in the resident's history should the PN consider the most likely to increase the client's risk for falls?