A client with a history of adrenal insufficiency is admitted to the intensive care unit with an acute adrenal crisis. The client is complaining of nausea and joint pain.
Vital signs are: temperature 102° F (38.9° C), heart rate 138 beats/minute, blood pressure 80/60 mm Hg. Which intervention should the nurse implement first?

Obtain an analgesic prescription.

Infuse an intravenous fluid bolus.

Administer PRN oral antipyretic.

Cover client with a cooling blanket.

Answer and Explanation

The Correct Answer is B

Choice A rationale
While obtaining an analgesic prescription might help to alleviate the client’s joint pain, it is not the first intervention that should be implemented. The client’s vital signs indicate that they are in a state of shock, which is a medical emergency.

Choice B rationale
Infusing an intravenous fluid bolus is often the first step in treating shock. The client’s low blood pressure and high heart rate suggest that they may be experiencing hypovolemic shock, which can be caused by a severe fluid loss. Administering fluids can help to increase blood volume and improve blood pressure.

Choice C rationale
Administering a PRN oral antipyretic would not address the client’s immediate need. The client’s high temperature is a concern, but the low blood pressure and high heart rate are more immediate concerns.

Choice D rationale

Covering the client with a cooling blanket would address the client’s high temperature, but it would not address the more immediate concerns of low blood pressure and high heart rate.

Nursing Test Bank

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Correct Answer is D

Explanation

Choice A rationale
While pallor can indicate various health issues such as anemia or low blood flow, it is not the most crucial finding when planning to provide a complete bed bath to a bedfast client.
Choice B rationale
Right-sided paralysis could affect the client’s ability to assist with the bath and could require special care or positioning. However, it is not the most crucial finding in this context.
Choice C rationale
2+ pitting edema of the feet could indicate fluid overload or poor circulation, but it is not the most crucial finding when planning to provide a complete bed bath.
Choice D rationale
This is the correct answer. Orthopnea, or difficulty breathing while lying flat, is the most crucial finding in this context. If a client has orthopnea, they may need to be positioned in a way that allows them to breathe comfortably during the bath.

A. Risk for constipation due to immobility. B. Risk for aspiration due to muscle weakness. C. Impaired physical mobility due to muscle rigidity. D. Self-care deficit due to motor disturbance.

Correct Answer is B

Explanation

Choice A rationale

While constipation due to immobility can be a concern for a client diagnosed with Parkinson’s disease, it is not the highest priority. The nurse should ensure that the client has a diet high in fiber and drinks plenty of fluids to prevent constipation. Regular physical activity can also help to stimulate bowel movements. However, this is not the most critical issue that needs to be addressed.

Choice B rationale

The risk for aspiration due to muscle weakness is the highest priority for a client diagnosed with Parkinson’s disease. This is because Parkinson’s disease can cause difficulties with swallowing, which can lead to aspiration. Aspiration can lead to serious complications such as pneumonia. The nurse should monitor the client for signs of difficulty swallowing and aspiration. The client may need to be referred to a speech therapist for a swallowing evaluation and may need modifications to their diet to make swallowing easier.

Choice C rationale

While impaired physical mobility due to muscle rigidity can be a concern for a client diagnosed with Parkinson’s disease, it is not the highest priority. The nurse should encourage the client to engage in regular physical activity to help manage muscle rigidity. Physical therapy may also be beneficial. However, this is not the most critical issue that needs to be addressed.

Choice D rationale

While a self-care deficit due to motor disturbance can be a concern for a client diagnosed with Parkinson’s disease, it is not the highest priority. The nurse should assess the client’s ability to perform activities of daily living and provide assistance as needed. Occupational therapy may also be beneficial. However, this is not the most critical issue that needs to be addressed.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment finding is most crucial when planning to provide a complete bed bath to a bedfast client?

Correct Answer is D

Explanation

When formulating a nursing care plan for a client diagnosed with Parkinson’s disease, which nursing problem should be given the highest priority?

Correct Answer is B

Explanation

The nurse identifies an electrolyte imbalance, elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours in a client with hepatic failure. Which intervention should the nurse include in the plan of care?

Which laboratory test results should the nurse monitor in a patient who has end-stage renal disease (ESRD)?

The nurse is providing postoperative care for an adolescent who had a left leg amputation due to osteosarcoma and is experiencing phantom limb pain. What non-pharmacological intervention should the nurse provide?

A patient with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. What schedule should the nurse follow to monitor the patient’s blood pressure after this procedure?

The nurse is collecting a heel-stick blood specimen for a neonatal screen, which includes thyroxine (T4) and thyroid- stimulating hormone (TSH) levels, prior to discharging a 2-day-old patient. When the parents ask why these tests are being conducted, which explanation should the nurse provide?

An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. What interventions should the nurse include in this client’s plan of care? Select all that apply.