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","B","C"]
Explanation
Choice A reason: Presenting a calm, supportive demeanor is an appropriate intervention for a client who is experiencing anxiety and hallucinations. The nurse should use a soothing tone of voice, maintain eye contact, and avoid arguing or challenging the client's perceptions. This can help reduce the client's agitation and promote trust.
Choice B reason: Reorienting to day and time frequently is an appropriate intervention for a client who is experiencing anxiety and hallucinations. The nurse should provide reality-based information and reminders about the client's situation, such as the reason for hospitalization, the name of the nurse, and the expected plan of care. This can help the client regain a sense of orientation and control.
Choice C reason: Administering an as needed (PRN) dose of lorazepam is an appropriate intervention for a client who is experiencing anxiety and hallucinations. Lorazepam is a benzodiazepine that can reduce anxiety, agitation, and psychotic symptoms by enhancing the effects of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter in the brain. The nurse should monitor the client's vital signs, level of sedation, and risk of falls after giving the medication.
Choice D reason: Turning the television on for distraction is not an appropriate intervention for a client who is experiencing anxiety and hallucinations. The television can increase the sensory stimulation and confusion for the client, and may worsen the hallucinations or delusions. The nurse should provide a quiet and safe environment for the client.
Choice E reason: Applying soft wrist restraints bilaterally is not an appropriate intervention for a client who is experiencing anxiety and hallucinations. Restraints can increase the anxiety and agitation for the client, and may cause physical or psychological harm. The nurse should use restraints only as a last resort when other less restrictive measures have failed to protect the client or others from harm.
Correct Answer is B
Explanation
Choice A reason: The humoral immune response is mediated by B cells that produce antibodies against specific antigens. However, this response is not the main problem in AIDS, because B cells are not directly affected by the human immunodeficiency virus (HIV) that causes AIDS. Therefore, this choice is incorrect.
Choice B reason: The cellular immune response is mediated by T lymphocytes that activate other immune cells, such as macrophages, to destroy infected or abnormal cells. This response is the main problem in AIDS, because HIV infects and destroys CD4+ T cells, which are essential for coordinating the cellular immunity. As a result, the client becomes susceptible to opportunistic infections, such as Pneumocystis jiroveci pneumonia. Therefore, this choice is correct.
Choice C reason: Bone marrow suppression of white blood cells can cause immunodeficiency, but it is not the primary cause of AIDS. Bone marrow suppression can occur as a side effect of some drugs or treatments, such as chemotherapy or radiation therapy, but it is not directly caused by HIV. Therefore, this choice is incorrect.
Choice D reason: Exposure to multiple environmental infectious agents can challenge the immune system, but it does not necessarily cause it to fail. The immune system can adapt and respond to different pathogens, unless it is compromised by an underlying condition, such as AIDS. Therefore, this choice is incorrect.
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