Nokea
The client diagnosed with Addison's disease is admitted to the emergency department after a day at the lake. The client is lethargic, forgetful, and weak. Which intervention should the nurse implement?
- A. Start an IV with an 18-gauge needle and infuse NS rapidly.
- B. Have the client wait in the waiting room until a bed is available.
- C. Obtain a permit for the client to receive a blood transfusion.
- D. Collect urinalysis and blood samples for a CBC and calcium level.
Correct Answer: A
Rationale: Lethargy, confusion, and weakness suggest Addisonian crisis; rapid NS infusion corrects hypotension and dehydration. Waiting, transfusions, and labs are inappropriate first steps.
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An adolescent with newly diagnosed Type I diabetes mellitus asks the nurse if he can continue to play football. What is the best answer for the nurse to give?
- A. Now that you have diabetes, you should not play football because you may get a cut that will not heal.'
- B. If you work with your physician to regulate the insulin dosage and your diet, you should be able to play football.'
- C. It would be better for you to work as equipment manager so you will not be under as much stress.'
- D. You can probably continue to play football if you can regulate it so that you have the same amount of exercise each day.'
Correct Answer: B
Rationale: With proper insulin and diet management, the adolescent can safely play football, supporting physical activity and normalcy.
The nurse is admitting a client to the neurological intensive care unit who is postoperative transsphenoidal hypophysectomy. Which data warrant immediate intervention?
- A. The client is alert to name but is unable to tell the nurse the location.
- B. The client has an output of 2,500 mL since surgery and an intake of 1,000 mL.
- C. The client's vital signs are T 97.6°F, P 88, R 20, and BP 130/80.
- D. The client has a 3-cm amount of dark-red drainage on the turban dressing.
Correct Answer: B
Rationale: High output (2,500 mL vs. 1,000 mL intake) suggests diabetes insipidus, requiring immediate intervention to prevent dehydration. Disorientation, normal vitals, and drainage are less urgent.
If a regular diet is ordered, which between-meal snack should the nurse offer to help regulate the client's blood glucose level?
- A. A small carton of milk
- B. A small apple
- C. A handful of raisins
- D. A slice of bread
Correct Answer: A
Rationale: A small carton of milk provides a balance of carbohydrates and protein to stabilize blood glucose in hypoglycemia.
Which client statement indicates a correct understanding of corticosteroid therapy for Addison's disease?
- A. I can stop the medication if I feel better.
- B. I need to take this medication daily.
- C. I should take it only during stress.
- D. I can double the dose if I'm sick.
Correct Answer: B
Rationale: Corticosteroid therapy for Addison's disease requires daily administration to replace deficient hormones and maintain physiological balance.
The client taking thyroid replacement hormone is hospitalized, and a thyroid replacement hormone is not prescribed. A week after being hospitalized, the nurse assesses that the client is becoming increasingly lethargic and has a decreased blood pressure, respiratory rate, temperature, and pulse. Which actions should be taken by the nurse? Place each nursing action in the order of priority.
- A. Warm the client
- B. Administer intravenous fluids
- C. Assist in ventilatory support
- D. Administer thyroxine as prescribed
Correct Answer: C,B,A,D
Rationale: Ventilatory support addresses decreased respiratory rate, IV fluids treat hypotension, warming prevents metabolic demand increase, and thyroxine corrects hypothyroidism.