A nurse is caring for a client who has Cushing's syndrome.Which of the following interventions should the nurse expect to perform? (Select all that apply.)
Assess for neck vein distention.
Monitor for an irregular heart rate.
Assess blood glucose level.
Monitor for postural hypotension.
Weigh the client daily.
Correct Answer : A,B,C,D,E
Choice A rationale
Assessing for neck vein distention helps monitor fluid overload, which is common in Cushing's syndrome due to cortisol's effects on fluid retention.
Choice B rationale
Monitoring for an irregular heart rate is important because cortisol can cause electrolyte imbalances and hypertension, which may affect heart rhythm.
Choice C rationale
Assessing blood glucose levels is essential since Cushing's syndrome can cause hyperglycemia due to cortisol's effects on glucose metabolism.
Choice D rationale
Monitoring for postural hypotension helps manage potential complications from cortisol's effects on blood pressure regulation.
Choice E rationale
Weighing the client daily is important for monitoring fluid retention and weight changes associated with Cushing's syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Wearing multiple layers of clothing helps to trap body heat, preventing hypothermia.
Choice B rationale
Drinking warm fluids from a thermos helps maintain body temperature by providing warmth.
Choice C rationale
Wearing gloves and earmuffs prevents heat loss from extremities, which is essential in preventing hypothermia.
Choice D rationale
Wearing a loose-fitting hat prevents heat loss from the head, which is a significant source of body heat loss.
Correct Answer is C
Explanation
Choice A rationale
Encouraging the client to drink cool water or sports drinks is appropriate for mild dehydration or heat exhaustion but not sufficient for severe heat-related illness like heat stroke, where immediate medical intervention is needed.
Choice B rationale
Administering acetaminophen 650 mg orally can help reduce fever, but it does not address the underlying issue of hyperthermia and will not provide immediate cooling needed in this emergency.
Choice C rationale
Starting an intravenous line and infusing 0.9% saline solution helps rapidly replace fluids lost through sweating and can stabilize the client's condition by rehydrating and cooling them effectively.
Choice D rationale
Encouraging rest and reassessing in 15 minutes would delay necessary medical treatment in a situation where immediate action is critical due to the severity of the client's symptoms.
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