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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D. What are the voices uttering?
Choice A rationale:
While it is essential to assess how the client copes with auditory hallucinations, asking this question alone does not provide specific information about the content of the hallucinations. Knowing what the voices are saying is vital in understanding the nature and potential impact of the hallucinations.
Choice B rationale:
Knowing when the voices are most disturbing can provide some insights into the pattern of the auditory hallucinations. However, this information alone may not fully address the client's current experience or their response to the hallucinations.
Choice C rationale:
Inquiring about which medication works best is important, but it should come after understanding the nature of the hallucinations. Medication management is a crucial aspect of treating schizophrenia, but gathering information about the content of the hallucinations helps in formulating an appropriate treatment plan.
Choice D rationale:
The correct choice. Knowing what the voices are uttering is essential in assessing the severity and potential impact of the auditory hallucinations on the client's well-being. This information will guide the healthcare team in providing targeted interventions and support to manage the symptoms effectively.
Correct Answer is C
Explanation
The correct answer is: Choice C - Check the pedal pulse in the affected leg.
Rationale:
- Choice A: Massage the calf and foot: While massage can be helpful for relieving muscle cramps in some cases, it is not the most appropriate first step in this situation. A leg cramp during labor could be a sign of a more serious condition, such as a blood clot (deep vein thrombosis or DVT). Massaging the area could potentially dislodge the clot and cause a pulmonary embolism (PE), a life-threatening condition.
- Choice B: Extend the leg and flex the foot: This maneuver may stretch the calf muscle and temporarily relieve the cramp, but it doesn't address the underlying cause. Additionally, extending the leg completely could be uncomfortable for the woman in labor.
- Choice C: Check the pedal pulse in the affected leg: This is the most crucial step. A weak or absent pedal pulse in the affected leg could be a strong indicator of DVT. Checking the pulse allows the nurse to assess for potential complications and escalate care if necessary.
- Choice D: Elevate the leg above the heart: Elevation can be helpful for reducing swelling and improving circulation, but it's not the primary concern in this case. Checking the pulse takes priority to assess for circulatory compromise.
Summary:
Leg cramps during labor can be caused by various factors, but it's essential to rule out more serious conditions like DVT. Checking the pedal pulse is the initial step to assess circulation and identify potential complications. If the pulse is weak or absent, the nurse should notify the healthcare provider immediately for further evaluation and treatment.
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