A nurse is caring for a client diagnosed with Addison's disease who is at risk for Addisonian crisis. The nurse is aware that which of the following is the priority assessment?
Monitor serum electrolytes
Monitor for signs of shock.
Monitor daily weights
Monitor Intake and output
The Correct Answer is B
A. While monitoring serum electrolytes is important, it is secondary to assessing for immediate life-threatening conditions.
B. Monitoring for signs of shock is the priority, as Addisonian crisis can lead to severe hypotension and shock, which requires immediate intervention.
C. Monitoring daily weights can help assess fluid status but is not critical in the context of an impending crisis.
D. Monitoring intake and output is important for overall assessment but does not directly address the immediate risks associated with Addisonian crisis.
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Correct Answer is B
Explanation
A. While monitoring serum electrolytes is important, it is secondary to assessing for immediate life-threatening conditions.
B. Monitoring for signs of shock is the priority, as Addisonian crisis can lead to severe hypotension and shock, which requires immediate intervention.
C. Monitoring daily weights can help assess fluid status but is not critical in the context of an impending crisis.
D. Monitoring intake and output is important for overall assessment but does not directly address the immediate risks associated with Addisonian crisis.
Correct Answer is A
Explanation
A. Assessing respiratory status and airway patency is the highest priority in this situation due to the risk of respiratory compromise from cervical spinal cord injuries, which can affect the diaphragm and other respiratory muscles.
B. While assessing extremity strength and sensation is important, it comes after ensuring the client’s airway and breathing are stable.
C. Pain management is essential, but addressing immediate life-threatening conditions takes precedence over pain assessment.
D. Assessing the client's level of consciousness is crucial for overall evaluation but does not take priority over ensuring adequate respiratory function in the context of a cervical spinal cord injury.