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: Irregular ulcer shapes and severe edema are characteristic of venous ulcers, which are caused by impaired venous return and increased capillary pressure. Venous ulcers are usually located near the medial malleolus and have a shallow depth.
Choice B reason: Hairless lower extremities and cool feet are signs of arterial insufficiency, which reduces blood flow and oxygen delivery to the tissues. Arterial ulcers are usually located on the toes, heels, or lateral malleoli and have a deep, punched-out appearance.
Choice C reason: Black ulcers and dependent rubor are also signs of arterial insufficiency, indicating tissue necrosis and inflammation. Dependent rubor is a reddish-blue color of the lower extremity that occurs when the leg is lowered below the level of the heart.
Choice D reason: Absent pedal pulses and shiny skin are also signs of arterial insufficiency, indicating reduced blood flow and atrophy of the skin. The skin may also be dry, scaly, or cracked.
Correct Answer is B
Explanation
Choice A reason: Applying prescribed lotions to the radiation site is a good action for a client with cancer receiving external beam radiation, because it can help moisturize and protect the skin from irritation and breakdown. The client should follow the instructions of the health care provider regarding the type and frequency of lotion application. Therefore, this choice does not indicate a need for further teaching.
Choice B reason: Washing the radiation site with antibacterial soap and water is a bad action for a client with cancer receiving external beam radiation, because it can cause dryness, inflammation, and infection of the skin. The client should use mild soap and water or saline solution to gently cleanse the area without rubbing or scrubbing. Therefore, this choice indicates a need for further teaching.
Choice C reason: Wearing clothing to cover the radiation site is a good action for a client with cancer receiving external beam radiation, because it can help shield the skin from sun exposure and friction. The client should wear loose-fitting, soft, cotton clothing that does not irritate or constrict the area. Therefore, this choice does not indicate a need for further teaching.
Choice D reason: Drying the area with patting motions after taking a shower is a good action for a client with cancer receiving external beam radiation, because it can help prevent trauma and infection of the skin. The client should avoid rubbing or scratching the area or using hair dryers or heating pads on it. Therefore, this choice does not indicate a need for further teaching.
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