A nurse assesses a patient with hypothyroidism who is admitted with acute appendicitis. The nurse notes that the patient's level of consciousness has decreased. What action does the nurse perform?
Restricts oral intake.
Monitor blood pressure every 4 hours.
Administer SQ insulin as prescribed.
Maintain a patent airway.
The Correct Answer is D
A decrease in the level of consciousness is a serious sign and could be an indication of worsening conditions. It is essential for the nurse to ensure that the patient's airway is open and clear, as a compromised airway can lead to hypoxia and a further decrease in consciousness. Therefore, maintaining a patent airway should be the nurse's priority action in this situation.
While monitoring blood pressure and restricting oral intake may be important interventions in certain situations, they are not the priority actions in this scenario. Administering SQ insulin may not be necessary for a patient with hypothyroidism and acute appendicitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","F","G"]
Explanation
Option A is incorrect because administering an ACE inhibitor may be a part of the patient's regular medication regimen, but it is not specific to preventing complications of diabetes mellitus while in the hospital.
Option b is incorrect because administering intravenous fluids at a high rate may result in fluid overload, electrolyte imbalances, and other complications, which may not be appropriate for this patient.
Option c is incorrect because administering glucagon is not a preventative measure, but rather an intervention for treating hypoglycemia.
Option d is correct because ensuring a well-lit path to the bathroom is important for fall prevention, but it does not directly address the prevention of complications of diabetes mellitus.
Option e is incorrect because encouraging the client to drink sugar-free liquids is a general recommendation for maintaining hydration and may not be specific to preventing complications of diabetes mellitus.
Option f is correct because teaching the client to rise slowly from the bed is important for preventing orthostatic hypotension, but it does not directly address the prevention of complications of diabetes mellitus.
Option g is correct because Patients with diabetes mellitus are at risk for hypoglycemia when taking insulin or oral hypoglycemic agents. Proper coordination of meal-time insulin with food delivery and consumption can help prevent hypoglycemia or hyperglycemia. This includes ensuring that the patient receives insulin at the appropriate time in relation to meals and monitoring blood glucose levels regularly.
Correct Answer is A
Explanation
In acute adrenal insufficiency, also known as Addison's disease, the adrenal glands are unable to produce enough cortisol and aldosterone hormones. These hormones play an important role in regulating sodium and potassium levels in the body. Therefore, a patient with acute adrenal insufficiency may have low sodium and high potassium levels in their blood.
The goal of therapy is to replace the deficient hormones and normalize the electrolyte levels in the body. If the current therapies are effective, the nurse would expect to see an increase in the patient's serum sodium levels because of aldosterone replacement therapy. Therefore, option a is the correct answer.
Decreasing serum chloride levels and decreasing blood glucose levels are not directly related to the treatment of acute adrenal insufficiency. In fact, a patient with acute adrenal insufficiency may have low serum chloride levels and low blood glucose levels due to the lack of cortisol hormone.
Increasing serum potassium levels would be an indicator of ineffective treatment or inadequate aldosterone replacement therapy, as aldosterone helps to regulate potassium levels in the body.
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