A nurse is caring for a client 4 hours following surgical repair of a penetrating brain injury. Which of the following assessments should be the nurse's priority?
Pain level assessment.
Wound site assessment.
Neurological assessment.
Respiratory status assessment.
The Correct Answer is C
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.
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Correct Answer is C
Explanation
A. Feeling fatigued is not indicative of a therapeutic response; rather, patients should experience increased energy levels with appropriate therapy.
B. Decreased thyroxine levels are not the primary goal of levothyroxine therapy, which aims to normalize thyroid hormone levels in the body.
C. Decreased thyroid-stimulating hormone (TSH) levels indicate that the body is responding well to levothyroxine, as TSH production decreases when thyroid hormone levels are adequate.
D. Bradycardia and hypotension are not desired effects of levothyroxine and indicate potential under-treatment or other issues rather than a therapeutic response.
Correct Answer is B
Explanation
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.