A client with Cushing syndrome as a result of a pituitary tumor has been admitted for a transsphenoidal hypophysectomy. What would be most important for the nurse to monitor before, during, and after surgery?

Oral temperature

Weight

Assessment of urine for blood

Blood glucose

Answer and Explanation

The Correct Answer is D

Reasoning:

Choice A reason: Oral temperature monitoring is important for detecting infection post-surgery but is not the primary concern in transsphenoidal hypophysectomy. Cushing’s syndrome causes hyperglycemia due to cortisol-induced insulin resistance, and surgical stress may exacerbate this, making glucose monitoring more critical than temperature in the perioperative period.

Choice B reason: Weight monitoring is relevant for long-term Cushing’s syndrome management due to fat redistribution, but it is not the most critical during surgery. Perioperative stress and fluid shifts have minimal immediate impact on weight, whereas glucose fluctuations from cortisol changes are more acute and require close monitoring.

Choice C reason: Assessing urine for blood is not a priority in transsphenoidal hypophysectomy. This surgery involves the pituitary gland, not the urinary tract, so hematuria is unlikely. Blood glucose fluctuations, driven by cortisol changes and surgical stress, are a more immediate concern requiring vigilant monitoring.

Choice D reason: Blood glucose monitoring is critical before, during, and after transsphenoidal hypophysectomy. Cushing’s syndrome causes hyperglycemia due to cortisol-induced insulin resistance. Surgery may alter cortisol levels, exacerbating glucose fluctuations, and postoperative adrenal insufficiency risk necessitates close glucose monitoring to manage metabolic complications effectively.

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Correct Answer is B

Explanation

Reasoning:

Choice A reason: Aspiration precautions are important in head injury to prevent pneumonia, particularly if consciousness is impaired, but they are not specific seizure prophylactic measures. Seizures require anticonvulsants to prevent neuronal hyperexcitability, making aspiration precautions a secondary concern unrelated to seizure prevention.

Choice B reason: Anticonvulsant medications, initiated early (e.g., day two), are standard for seizure prophylaxis in head injury. Trauma can cause cortical irritation, increasing seizure risk. Drugs like levetiracetam stabilize neuronal activity, preventing seizures, which could worsen brain injury or ICP, making this the primary measure.

Choice C reason: Intubation and ventilator support are used for severe head injuries with compromised airway or breathing but are not seizure prophylaxis. Seizures are managed with anticonvulsants, as mechanical ventilation does not address neuronal excitability, making this inappropriate for seizure prevention.

Choice D reason: Antiemetic medications manage nausea but are not seizure prophylactic measures. While vomiting may occur post-head injury, it does not prevent seizures, which result from cortical irritability. Anticonvulsants directly target seizure risk, making antiemetics irrelevant to this specific intervention goal.

A. Initiating early mobilization B. Maximizing partial pressure of carbon dioxide (PaCO2) C. Positioning the client to avoid intracranial pressure (ICP) D. Administering hypertonic intravenous (IV) solution

Correct Answer is A

Explanation

Reasoning:

Choice A reason: Early mobilization post-ischemic stroke is critical during recovery to prevent complications like deep vein thrombosis, pneumonia, and muscle atrophy. It promotes neuroplasticity, improves circulation, and enhances functional recovery, making it a priority intervention in the immediate recovery period to optimize outcomes and reduce disability.

Choice B reason: Maximizing PaCO2 is not appropriate post-ischemic stroke. Elevated CO2 causes cerebral vasodilation, potentially increasing ICP, which is harmful. Maintaining normal CO2 levels supports cerebral perfusion without exacerbating edema, making this intervention irrelevant or potentially dangerous in stroke recovery.

Choice C reason: Positioning to avoid ICP is more relevant for hemorrhagic stroke, where ICP is a concern. In ischemic stroke, ICP is less likely unless severe edema occurs. Early mobilization takes precedence to prevent complications and promote recovery, making ICP positioning a secondary concern.

Choice D reason: Administering hypertonic IV solutions is used in cases of cerebral edema or elevated ICP, more common in hemorrhagic stroke. In ischemic stroke, hydration with isotonic fluids supports perfusion, but early mobilization is the priority to enhance recovery and prevent immobility-related complications.

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A client with Cushing syndrome as a result of a pituitary tumor has been admitted for a transsphenoidal hypophysectomy. What would be most important for the nurse to monitor before, during, and after surgery?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client sustained a head injury as a result of trauma. The health care provider has instituted seizure prophylactic measures. The nurse anticipates which specific measures being initiated for this client?

Correct Answer is B

Explanation

Nursing care during the immediate recovery period from an ischemic stroke should normally prioritize which intervention?

Correct Answer is A

Explanation

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