A nurse is assessing a client with a history of Addison's disease admitted for surgery. The nurse is aware that which of the following is an expected assessment finding?
Weight gain
Hyperpigmentation
Elevated blood pressure
Purple striations
The Correct Answer is B
A. Weight gain is not typical in Addison's disease; instead, weight loss is common.
B. Hyperpigmentation, particularly in sun-exposed areas and skin folds, is a classic symptom of Addison's disease due to elevated ACTH levels.
C. Low blood pressure, not elevated, is common due to decreased cortisol levels.
D. Purple striations are more commonly seen in Cushing's syndrome rather than Addison's disease.
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Correct Answer is B
Explanation
A. Low levels of PTH would primarily affect calcium metabolism and would not directly explain short stature or delayed menarche.
B. Impaired production of GH is most likely the cause of short stature, as growth hormone plays a critical role in growth and development during childhood.
C. Lack of ACTH affects adrenal hormone production but does not directly lead to short stature or delayed menarche.
D. Impaired production of T3 and T4 would affect metabolism and growth but is less likely to be the primary cause of the symptoms presented compared to growth hormone deficiencies.
Correct Answer is C
Explanation
A. While pain level assessment is important, it is not the priority immediately after a significant brain injury where neurological changes may occur.
B. Wound site assessment is also essential but does not take precedence over neurological assessment in this context.
C. A neurological assessment is the priority to identify any changes in the client's condition that may indicate complications such as increased intracranial pressure, which can occur after brain surgery.
D. Respiratory status assessment is important but is usually addressed through monitoring and interventions related to neurological function, as brain injuries can affect respiratory drive and function.