After performing a head-to-toe assessment for a client with Addison's disease, the nurse reports findings to the healthcare provider. The findings include moist mucous membranes, strong palpable peripheral pulses, and blood pressure 132/88 mm Hg. The client verbalizes understanding of the illness and importance of taking medications every day. Which action should the nurse implement?
Make a referral for social services at home.
Continue to limit daily fluid intake to 500 mL.
Begin preparing the client for discharge home.
Recommend strict intake and output monitoring.
The Correct Answer is C
Choice A reason: A referral for social services at home is not necessary for a client with Addison's disease who has stable vital signs, adequate hydration, and good self-care knowledge.
Choice B reason: Limiting daily fluid intake to 500 mL is not appropriate for a client with Addison's disease, who is at risk of dehydration and hypotension. The client should drink fluids according to thirst and urine output.
Choice C reason: Preparing the client for discharge home is the best action for the nurse to implement, as the client has no signs of complications or deterioration from Addison's disease. The client should be able to manage the condition at home with regular follow-up and medication adherence.
Choice D reason: Strict intake and output monitoring is not required for a client with Addison's disease who has normal blood pressure, moist mucous membranes, and strong peripheral pulses. These indicate adequate fluid balance and renal function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Gastroccult positive emesis indicates the presence of blood in the vomit, which is a sign of a serious complication such as anastomotic leak, ulcer, or bleeding. The nurse should notify the physician and monitor the client's vital signs and hemoglobin level.
Choice B reason: Strong foul smelling flatus is a common side effect of BPD, which involves bypassing a large portion of the small intestine and creating a connection between the stomach and the colon. This results in malabsorption and bacterial overgrowth, which produce gas and odor.
Choice C reason: Complaint of poor night vision is a sign of vitamin A deficiency, which can occur after BPD due to reduced absorption of fat-soluble vitamins. The nurse should advise the client to take vitamin supplements and eat foods rich in vitamin A, such as carrots, sweet potatoes, and spinach.
Choice D reason: Loose bowel movements are another common side effect of BPD, which causes diarrhea and steatorrhea (fatty stools). The nurse should encourage the client to drink fluids with electrolytes and avoid foods that worsen diarrhea, such as greasy, spicy, or sugary foods.
Correct Answer is A
Explanation
Choice A reason: Pupillary changes to ipsilateral dilation indicate increased intracranial pressure, which is a life-threatening complication of stroke. The nurse should notify the physician and prepare for emergency measures.
Choice B reason: Left-sided facial drooping and dysphagia are common signs of right hemisphere stroke, but they do not require immediate intervention by the nurse. The nurse should monitor the patient's swallowing ability and provide oral care.
Choice C reason: Orientation to person and place only is a sign of impaired cognition, which is also common in right hemisphere stroke. The nurse should assess the patient's memory, judgment, and attention span.
Choice D reason: Unequal bilateral hand grip strengths are a sign of hemiparesis, which is a weakness on one side of the body. The nurse should assist the patient with mobility and prevent contractures.
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