A patient is admitted to the hospital in Addisonian Crisis a month after a diagnosis of Addison’s disease. The nurse identifies the nursing diagnosis of ineffective therapeutic regimen management related to lack of knowledge of management of the condition when the patient says:
“I double my dose of hydrocortisone on the days that I go for a run.”
“I had the stomach flu earlier this week and couldn't take the hydrocortisone.”
“I frequently eat at restaurants, and so my food has a lot of added salt."
“I do yoga exercises almost every day to help me reduce stress and relax.”
The Correct Answer is B
The statement "I had the stomach flu earlier this week and couldn't take the hydrocortisone" indicates that the patient may not be adhering to their prescribed medication regimen, which can lead to an Addisonian crisis. Therefore, the nursing diagnosis of ineffective therapeutic regimen management related to lack of knowledge of management of the condition is appropriate.
Addison’s disease is a condition in which the adrenal glands do not produce enough cortisol and aldosterone. Hydrocortisone is a glucocorticoid medication that is often used to replace the cortisol that the adrenal glands are not producing. In the Addisonian crisis, the body is unable to produce the necessary levels of cortisol and aldosterone, which can lead to potentially life-threatening complications such as hypotension, dehydration, and electrolyte imbalances.
The other statements may indicate areas where patient education is needed, but they do not directly relate to the immediate risk of an Addisonian crisis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Based on the given documentation, the nurse suspects that the client has respiratory alkalosis. The client's ABG results show a pH of 7.52, which indicates alkalosis and the PaO2 level is slightly low, suggesting respiratory involvement. Rapid breathing (RR44) and wheezing also support the possibility of respiratory alkalosis.
Correct Answer is B
Explanation
Counting sponges, needles, and surgical instruments is an intraoperative activity that is specific to the circulating function of the perioperative nurse. The nurse is responsible for maintaining an accurate count of all surgical items to prevent leaving any foreign objects inside the patient after the surgery. This is a crucial task to ensure patient safety and prevent any potential complications that may arise from such errors.
Option a. admitting, identifying, and assessing the patient, is a preoperative function that is usually performed by the preoperative nurse.
Option c. passing instruments to the surgeon and assistants, is a scrub nurse function that requires knowledge of the surgical procedure and a sterile technique.
Option d. preparing the instrument table and sterile equipment is also a scrub nurse function that requires expertise in sterile technique, knowledge of surgical procedures, and the ability to maintain a sterile environment.
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