The nurse is caring for a patient who was treated for Addisonian crisis.
What clinical change indicates to the nurse that the prescribed therapy was effective?
Increase of 25 mmHg in the patient's systolic blood pressure.
An increase in the serum potassium level from 3.5 to 5.6 mEq/dL.
Patient complains of headache and is showing signs of restlessness.
The patient has normal temperature with pallor to the skin.
The Correct Answer is A
Choice A rationale
An increase in systolic blood pressure by 25 mmHg indicates a positive response to therapy for Addisonian crisis. Addisonian crisis involves severe hypotension due to low levels of cortisol and aldosterone, which regulate blood pressure. Cortisol replacement therapy helps to increase blood pressure by enhancing the responsiveness of blood vessels to catecholamines and promoting sodium and water retention. This improvement is critical for stabilizing the patient and restoring hemodynamic balance.
Choice B rationale
An increase in serum potassium level from 3.5 to 5.6 mEq/dL suggests hyperkalemia, which is a sign of worsening condition, not improvement. Addisonian crisis is characterized by hyperkalemia due to aldosterone deficiency, which impairs potassium excretion. Effective treatment would normalize potassium levels rather than increase them.
Choice C rationale
Complaints of headache and signs of restlessness may indicate adverse effects or complications, rather than therapeutic efficacy. These symptoms could result from inadequate or excessive dosing of corticosteroids or other underlying issues. Monitoring patient response and adjusting treatment is essential.
Choice D rationale
Normal temperature with pallor to the skin does not indicate effective therapy for Addisonian crisis. Pallor may reflect ongoing hypoperfusion or anemia. The absence of fever is not a definitive marker of therapeutic success. Key indicators include hemodynamic stability and normalized electrolytes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Placing the patient in a private, lead-lined room is unnecessary for external radiation therapy, which does not make the patient radioactive. This consideration is more applicable to internal radiation therapy (brachytherapy), where radioactive materials are placed inside the body.
Choice B rationale
While dosimeter badges are essential for monitoring radiation exposure, they are more relevant for healthcare workers who may be exposed to radiation, not for patients receiving external radiation therapy. The patient themselves are not a source of radiation exposure.
Choice C rationale
Monitoring the patient's skin integrity is crucial because external radiation can cause skin irritation and damage. Avoiding exposure to extreme heat or cold helps prevent additional skin trauma and promotes healing.
Choice D rationale
Restricting visitors and posting radioactive precautions signs are unnecessary for patients receiving external radiation therapy. These precautions are more applicable to internal radiation therapy, where the patient may emit radiation.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Administering filgrastim (G-CSF) as ordered is crucial for patients with a low ANC. Filgrastim stimulates the production of neutrophils in the bone marrow, helping to reduce the risk of infections. For a patient with an ANC of 500/mm³, which indicates severe neutropenia, this intervention can significantly enhance the immune response and decrease susceptibility to infections.
Choice B rationale
Keeping the patient's central line insertion site clean and open to air is incorrect and could increase the risk of infection. Central line sites must be covered with a sterile dressing to prevent bacterial contamination and infection. Open exposure to air can introduce pathogens, especially in a patient with neutropenia.
Choice C rationale
Educating the patient and family about food safety and hygiene is essential for preventing infections in patients with neutropenia. Proper food handling and hygiene practices reduce the risk of bacterial and other infections. This education can help patients and their families implement measures to protect the patient from potential sources of infection.
Choice D rationale
Providing a high-protein, high-calorie diet is appropriate for supporting the patient's overall health and recovery. High-protein and high-calorie foods support the body's immune function, repair tissues, and maintain energy levels. Proper nutrition is vital for patients with leukemia to help them cope with the demands of their illness and treatment.
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