A client was brought to the emergency room with complains of difficulty of breathing. What can lead the nurse to suspect that the client is experiencing acute respiratory distress syndrome (ARDS)?

Correct Answer: C

Rationale: Step-by-step rationale for choice C being correct: 1. Restlessness: Indicates increased work of breathing and hypoxia. 2. Suprasternal retractions: Sign of respiratory distress. 3. paO2 of 62: Indicates severe hypoxemia, common in ARDS. Summary: A: Enlarged heart on x-ray does not directly indicate ARDS. B: Thick green sputum suggests infection, not specific to ARDS. D: Wheezes and slow respirations are not typical of ARDS, and pCO2 is normal in ARDS.

Correct Answer: B

Rationale: The correct answer is B because hyperkalemia presents with symptoms such as muscle weakness, diarrhea, and ECG changes. Muscle weakness is a common sign due to potassium's effect on neuromuscular function. Diarrhea can lead to potassium loss. ECG changes, such as peaked T waves and widened QRS complexes, indicate cardiac involvement. Assessing for these symptoms helps monitor the severity of hyperkalemia and guide treatment. Other choices are incorrect because assessing for fever and chest pain (choice A) are not specific to hyperkalemia. Encouraging fluid restriction (choice C) may not directly address hyperkalemia. Preparing for a cardiac ultrasound (choice D) is not an immediate intervention for hyperkalemia.

Correct Answer: D

Rationale: The correct answer is D. In Addison's disease, the adrenal glands do not produce enough cortisol and aldosterone. This leads to sodium and potassium imbalances. Low aldosterone causes sodium loss and potassium retention, resulting in sodium and potassium abnormalities. The other choices, A, B, and C, do not directly relate to Addison's disease. Calcium and phosphorus abnormalities are not typically associated with Addison's disease. Sodium and chloride, and chloride and magnesium imbalances are not primary concerns in Addison's disease. Therefore, staying alert for signs and symptoms of sodium and potassium abnormalities is crucial in managing and monitoring a client with Addison's disease.

Correct Answer: A

Rationale: The correct answer is A: Hypocortisolism. After a transsphenoidal hypophysectomy, the pituitary gland is removed or partially removed, leading to decreased cortisol production. Signs of hypocortisolism include weakness, fatigue, hypotension, weight loss, and electrolyte imbalances. Hyperglycemia (B) is not typically associated with this procedure. Hypoglycemia (C) is not a common concern post-hypophysectomy. Hypercalcemia (D) is not directly related to pituitary gland removal. Therefore, assessing for hypocortisolism is crucial for early detection and management post-surgery.

Correct Answer: A

Rationale: The correct answer is A: Deficient fluid volume related to osmotic diuresis. With a serum glucose level of 618mg/dl, the client is likely experiencing diabetic ketoacidosis, leading to excessive urination (osmotic diuresis) and dehydration. The priority is to address fluid volume deficit to prevent hypovolemic shock. The other options are not the priority because: B: Decreased cardiac output is a result of the increased heart rate, not the primary issue. C: Imbalanced nutrition is important but not as urgent as fluid volume deficit. D: Ineffective thermoregulation is a concern but not the priority in this scenario.