A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include: sodium 129 mEq/L (129 mmol/L), glucose 54 mg/dl (2.97 mmol/L) and potassium 5.3 mEq/L (5.3 mmol/L).

When reporting the findings to the healthcare provider, the nurse anticipates a prescription for which intravenous medication?

Reference Ranges

Sodium [Reference Range: Adult 136 to 145 mEq/L (136 to 145 mmol/L)

Glucose (Reference Range: 0 to 50 years: 74 to 106 mg/dl. (4.1 to 5.9 mmol/L))

Potassium [Reference Range: 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)

Broad spectrum antibiotic.

Regular insulin.

Hydrocortisone.

Potassium chloride.

Answer and Explanation

The Correct Answer is C

The client with Addison's disease is experiencing weakness, confusion, and dehydration, which can be indicative of an adrenal crisis. The low sodium level (129 mEq/L) and low glucose level (54 mg/dl) further support this suspicion. An acute viral infection can trigger an adrenal crisis in individuals with Addison's disease.

Intravenous hydrocortisone, a glucocorticoid, is the treatment of choice for managing an adrenal crisis. It helps to replenish cortisol levels and stabilize the client's condition.

Hydrocortisone helps in restoring the body's stress response and regulating electrolyte and glucose levels.

A broad-spectrum antibiotic may be necessary if there is evidence of a bacterial infection, but it does not directly address the symptoms associated with Addison's disease.

Regular insulin is used for managing high blood glucose levels in conditions such as diabetes, but in this case, the client has low glucose levels, so insulin is not the appropriate intervention.

Potassium chloride is a medication used to treat low potassium levels (hypokalemia), but the client's potassium level is within the reference range (5.3 mEq/L). Therefore, potassium chloride is not indicated in this situation.

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Correct Answer is D

Explanation

The client's statement of feeling worthless most days and having no interest in activities she previously enjoyed indicates a potential risk for self-directed violence, including self-harm or suicidal ideation. These signs are significant and require immediate attention and intervention by the nurse.

Assessing and addressing the client's risk for self-directed violence is of utmost importance to ensure her safety and well-being. The nurse should initiate a thorough assessment of the client's mental health, including assessing for any suicidal ideation, intent, or plans. It is crucial to establish a supportive and non-judgmental environment for the client to express her feelings and concerns.

The nurse should collaborate with the healthcare team to develop an appropriate care plan that may involve interventions such as close observation, involving a mental health professional, implementing safety measures, and providing emotional support.

While addressing other nursing problems, such as anxiety, imbalanced nutrition, and chronic low self-esteem, is important, the immediate concern is the client's risk for self-directed violence due to her feelings of hopelessness.

A. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema. B. Secure client consent for coronary angiography and percutaneous coronary intervention. C. Administer four 81 mg aspirin tablets providing instructions to chew before swallowing. D. Place an indwelling urinary catheter and institute strict intake and output measurements.

Correct Answer is C

Explanation

Given the client's symptoms of constant chest pressure that is unrelieved with rest, along with the client's appearance of anxiety, pallor, and diaphoresis, it indicates a high likelihood of an acute coronary event, such as a myocardial infarction (heart attack). In this situation, the nurse should prioritize immediate actions that address the potential cardiac emergency.

Aspirin is an essential medication in the initial management of acute coronary syndrome, including unstable angina and myocardial infarction. It helps to inhibit platelet aggregation and reduce the risk of clot formation in the coronary arteries. The chewable form of aspirin is recommended because it allows for more rapid absorption.

While evaluating extremities for perfusion, pulse volume, and pitting edema is important in assessing the client's overall cardiovascular status, it is not the immediate next step when faced with a suspected acute coronary event.

Securing client consent for coronary angiography and percutaneous coronary intervention (PCI) is a relevant step in the management of unstable angina and myocardial infarction, but it is not the immediate action to be taken in the emergency department. The client requires stabilization and initial medical interventions before procedural consent can be obtained.

Placing an indwelling urinary catheter and instituting strict intake and output measurements is not a priority action in this situation. The focus should be on addressing the potential acute coronary event and ensuring the client's cardiac stability. Urinary catheterization and monitoring of intake and output can be considered later, if necessary.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

Correct Answer is C

Explanation

The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client Indicates that the teaching was effective?

A client with diabetes insipidus (DI) has an average urinary output of 500 ml. of dilute urine every hour for the last 4 hours. Which laboratory test is most important for the nurse to monitor?

The nurse discovers that an older client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history?

An older client is taken to the clinic by the spouse, who appears extremely worried. The spouse reports to the nurse that the client started to not make any sense and asked to visit a brother who has been dead for many years. Which action(s) should the nurse take? (Select all that apply.)

A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In which, order should the nurse implement these interventions? (Arrange the actions in order of priority, with the highest priority first, and least priority last or at the bottom.)

The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN?

A client with unilateral hearing loss is admitted for a scheduled surgery. Which technique should the nurse use to provide education about pain relief options?