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 ["B","D","E"]
Explanation
Choice A rationale: Oral health indicates the absence of mucositis or other oral complications, which is good, but it doesn't necessarily reflect overall improvement in the client's cancer or chemotherapy response.
Choice B rationale: The absence of bleeding episodes is significant. This suggests that the client's platelet count has improved, reducing the risk of bleeding, which is an important indicator of recovery.
Choice C rationale: While weight maintenance or gain can be an indicator of health improvement, the slight decrease in weight from January to February (70.5 kg to 69 kg) does not suggest an improvement.
Choice D rationale: An increase in the WBC count to within the normal range (4.2 x 10⁹/L) is a positive sign. It indicates that the client’s immune system is recovering, which is crucial during chemotherapy.
Choice E rationale: The improvement in platelet count to within the normal range (150 x 10⁹/L) suggests a reduced risk of bleeding and reflects better bone marrow function, which is a positive outcome of the treatment.
Correct Answer is ["A","C"]
Explanation
Choice A rationale:
Tachycardia: Heatstroke often leads to an elevated heart rate due to the body's attempt to cool down and compensate for increased body temperature. The heart rate of 120 beats per minute noted in the client is consistent with tachycardia.
Choice B rationale:
Hallucinations: While confusion and disorientation are common symptoms of heatstroke, hallucinations are not typical findings associated with heatstroke. Therefore, this is not a consistent finding for this diagnosis.
Choice C rationale:
Skin is hot, dry: One of the hallmark signs of heatstroke is hot, dry skin, which results from the body's inability to regulate its temperature effectively. The client's skin being hot to the touch and dry aligns with this characteristic.
Choice D rationale:
Bradycardia: This is characterized by a slower than normal heart rate. Since the client presents with a heart rate of 120 beats per minute, which indicates tachycardia, bradycardia is not a finding consistent with heatstroke.
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