A nurse is caring for a client who has Cushing’s syndrome. The nurse should recognize that which of the following are manifestations of Cushing’s syndrome? (Select all that apply)

Choice A reason:

Elevating the head of the client’s bed can help reduce blood pressure slightly by promoting venous return and decreasing intracranial pressure. However, this action alone is not sufficient to address the severe hypertension (254/139 mm Hg) the client is experiencing. Immediate medical intervention is required to prevent complications such as stroke, heart attack, or organ damage.

Choice B reason:

Contacting the Rapid Response Team is the highest priority action. The Rapid Response Team is trained to handle critical situations and can provide immediate interventions to stabilize the client’s condition. Severe hypertension at this level requires urgent medical attention to prevent life-threatening complications. The team can administer medications to lower blood pressure quickly and monitor the client closely.

Choice C reason:

Telling the client to report vision changes is important because vision changes can indicate hypertensive retinopathy or increased intracranial pressure. However, this action is not the immediate priority. The client’s blood pressure needs to be controlled urgently to prevent further complications.

Choice D reason:

Inserting a peripheral IV is necessary for administering medications and fluids. While this is an important step, it should follow the immediate action of contacting the Rapid Response Team. The team can then use the IV access to administer antihypertensive medications promptly.

Choice E reason:

Initiating seizure precautions is important because severe hypertension can lead to seizures. However, this action is not the first priority. The primary focus should be on stabilizing the client’s blood pressure through immediate medical intervention.

Choice A Reason:

Documenting that the nasogastric tube is in the correct place is not appropriate in this scenario. A gastric pH of 7.35 is too high for stomach contents, which typically have a pH between 1.5 and 3.5. This high pH suggests that the tube may be misplaced, possibly in the respiratory tract or another non-gastric location. Therefore, documenting the tube as correctly placed could lead to serious complications if the tube is indeed misplaced.

Choice B Reason:

Notifying the health care provider is the most appropriate action. A pH of 7.35 is indicative of a potential misplacement of the nasogastric tube. The health care provider needs to be informed immediately to take corrective actions, such as ordering an X-ray to confirm the tube’s placement or re-evaluating the tube’s position. This step is crucial to ensure patient safety and prevent complications such as aspiration pneumonia or other adverse effects.

Choice C Reason:

Checking for placement by auscultating for air injected into the tube is an outdated and unreliable method. This technique can sometimes give false assurance of correct placement, as the sound of air can be heard even if the tube is in the respiratory tract. Current best practices recommend using pH testing and radiographic confirmation for accurate placement verification.

Choice D Reason:

Retesting the pH using another strip might seem like a reasonable step, but it is not the best immediate action. If the initial pH test shows a value of 7.35, it is unlikely that retesting will yield a significantly different result. The priority should be to notify the health care provider to address the potential misplacement promptly.

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