A nurse is caring for a client who has Addison’s disease and is at risk for Addisonian crisis. Which of the following actions should the nurse take?
Weigh the client daily.
Restrict food intake.
Administer oral corticosteroids.
Provide a low carbohydrate diet.
The Correct Answer is C
Choice A Reason:
Weigh the client daily: While monitoring weight is important for clients with Addison’s disease, it is not the primary action to prevent an Addisonian crisis. Daily weight monitoring helps track fluid balance and detect any sudden changes that might indicate complications, but it does not directly address the hormonal imbalance that characterizes Addisonian crisis.
Choice B Reason:
Restrict food intake: Restricting food intake is not recommended for clients with Addison’s disease. Proper nutrition is crucial for maintaining energy levels and overall health. Clients with Addison’s disease need a balanced diet to manage their condition effectively. Restricting food intake could lead to malnutrition and exacerbate symptoms.
Choice C Reason:
Administer oral corticosteroids: This is the correct action. Addison’s disease is characterized by insufficient production of cortisol and aldosterone by the adrenal glands. Administering oral corticosteroids helps replace the deficient hormones and manage the symptoms of Addison’s disease. During an Addisonian crisis, immediate administration of corticosteroids is critical to prevent severe complications such as shock, coma, or even death.
Choice D Reason:
Provide a low carbohydrate diet: A low carbohydrate diet is not specifically recommended for clients with Addison’s disease. Instead, a balanced diet that includes adequate carbohydrates, proteins, and fats is essential. Carbohydrates are important for maintaining energy levels, especially since clients with Addison’s disease may experience fatigue and weakness. Restricting carbohydrates could lead to low blood sugar levels, which can be dangerous for these clients.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Thirst is a common and expected symptom after an EGD, especially if the client has been fasting before the procedure. It does not typically indicate a complication and can be managed by gradually reintroducing fluids as tolerated. Therefore, thirst does not require further nursing assessment beyond routine post-procedure care.
Choice B Reason:
A sore throat is also a common symptom following an EGD. The procedure involves passing an endoscope through the throat, which can cause temporary irritation and discomfort. This symptom usually resolves on its own within a few days and does not indicate a serious complication. Therefore, a sore throat does not require further nursing assessment beyond providing comfort measures such as lozenges or warm saltwater gargles.
Choice C Reason:
Abdominal distention is a concerning symptom that requires further nursing assessment. It can indicate complications such as perforation, bleeding, or infection following the EGD. Perforation of the gastrointestinal tract is a rare but serious complication that can lead to peritonitis and sepsis if not promptly addressed. Therefore, any signs of abdominal distention should be reported to the provider immediately for further evaluation and intervention.
Choice D Reason:
Drowsiness is a common side effect of the sedatives used during the EGD procedure. It is expected that the client may feel drowsy or sleepy for a few hours after the procedure as the sedative wears off. This symptom does not typically require further nursing assessment unless it persists for an unusually long time or is accompanied by other concerning symptoms such as difficulty breathing or altered mental status.
Correct Answer is ["A"]
Explanation
Choice A: Monitor for hypernatremia.
Hypernatremia, or high sodium levels in the blood, is a common complication of diabetes insipidus due to excessive water loss and insufficient water intake. Monitoring for hypernatremia involves regular blood tests to check sodium levels. Symptoms of hypernatremia include extreme thirst, confusion, muscle twitching, and seizures. Early detection and management are crucial to prevent severe complications.
Choice B: Monitor neuro status.
Monitoring neurological status is essential in patients with diabetes insipidus because severe hypernatremia can lead to neurological symptoms such as confusion, irritability, seizures, and even coma. Regular assessments of mental status, level of consciousness, and neurological function help in early detection of complications and timely intervention.
Choice C: Monitor for hyponatremia.
While hyponatremia (low sodium levels) is less common in diabetes insipidus, it can occur if there is excessive water intake without adequate sodium replacement. Symptoms include headache, nausea, vomiting, confusion, and seizures. Monitoring sodium levels helps in maintaining a balance and preventing complications.
Choice D: Monitor urine specific gravity.
Urine specific gravity measures the concentration of solutes in the urine. In diabetes insipidus, urine is typically very dilute, with a specific gravity of less than 1.005. Regular monitoring helps in assessing the effectiveness of treatment and the patient’s hydration status. It also aids in differentiating diabetes insipidus from other conditions with similar symptoms.
Choice E: Monitor strict I&O.
Strict monitoring of intake and output (I&O) is crucial in managing diabetes insipidus. This involves accurately measuring all fluids consumed and excreted to ensure proper hydration and electrolyte balance. It helps in identifying trends in fluid loss and guiding appropriate fluid replacement therapy.
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