. During the first 24 hours after a client is diagnosed with Addisonian crisis, which of the following should the nurse perform frequently?

Correct Answer: D

Rationale: During the first 24 hours after a client is diagnosed with Addisonian crisis, it is crucial for the nurse to frequently assess the client's vital signs. Addisonian crisis is a life-threatening condition resulting from acute adrenal insufficiency. Monitoring vital signs such as blood pressure, heart rate, respiratory rate, and temperature can provide valuable information about the client's condition and response to treatment. Changes in vital signs may indicate worsening or improvement in the client's health status, helping the nurse to make timely interventions and adjustments in the client's care plan. Regular assessment of vital signs is essential in managing the client's stability and preventing complications during this critical period.

Correct Answer: A

Rationale: The most important instruction to include in the client's teaching plan would be to maintain a moderate exercise routine (Option A). Regular physical activity is important for overall health, including helping to maintain bone health and strength. This is particularly crucial for individuals with hyperparathyroidism who are declining surgery and opting for hormone replacement therapy, as exercise can help to support bone density and reduce the risk of fractures. However, it is essential to emphasize that the exercise should be moderate and appropriate for the individual's current fitness level, as excessive exercise can have negative effects on bone health in this population.

Correct Answer: B

Rationale: Opening the patient's jaw and inserting a mouth gag is not part of the appropriate nursing care for a patient experiencing a convulsive seizure. Doing so can potentially harm the patient by causing injury to the teeth, jaw, or airway. It is important to protect the patient's airway during a seizure, but this can be done by positioning the patient on their side with the head flexed forward, ensuring a clear airway without the need for a mouth gag.

Correct Answer: A

Rationale: In caring for a patient with expressive aphasia like Mr. Reyea, providing positive feedback when he uses a word correctly is essential for reinforcing and encouraging communication efforts. This positive reinforcement can help boost his confidence and motivation to continue trying to communicate effectively. It is important to support and acknowledge any progress made, as communication difficulties can be frustrating for individuals with aphasia. Waiting for him to verbally state needs regardless of how long it may take, as well as suggesting that he get help at home because the disability is permanent, may not be the most therapeutic or supportive approaches. Helping the family accept that Mr. Reyea cannot participate in verbal communication should not be the primary focus, as there are strategies and therapies that can help improve communication abilities in patients with aphasia.

Correct Answer: B

Rationale: Giving Mr. Franco frequent mouth care is important to remove dried blood when the tongue is bitten during a seizure. Seizures can cause involuntary biting of the tongue, leading to the accumulation of dried blood in the mouth. If this blood is not removed promptly, it can result in discomfort, infection, and potential complications. Regular oral care helps maintain oral hygiene and prevents any issues related to oral trauma during seizures, promoting overall health and well-being for the patient.