The nurse is assessing a patient with Cushing syndrome. Which finding should the nurse report for immediate follow-up?
Serum potassium 2.5 mEq/L and blood pressure 150/90 mmHg
Serum phosphorus 3 mg/dL and hirsutism
Serum calcium 10 mg/dl, and reports of feelings of depression
Serum sodium 145 mEq/L and reports of muscle weakness
The Correct Answer is A
A. Serum potassium 2.5 mEq/L and blood pressure 150/90 mmHg - This combination of severe hypokalemia (low potassium) and elevated blood pressure is a concerning finding. It can lead to serious cardiac complications and requires immediate attention.
B. Serum phosphorus 3 mg/dL and hirsutism - While low serum phosphorus may be seen in Cushing syndrome, it is not an immediate concern. Hirsutism (excessive hair growth) is a characteristic feature of Cushing syndrome.
C. Serum calcium 10 mg/dL, and reports of feelings of depression - Although an elevated serum calcium level is not typical in Cushing syndrome, it is not an immediate concern. Reports of depression should be addressed but do not require immediate follow-up.
D. Serum sodium 145 mEq/L and reports of muscle weakness - These findings are not indicative of immediate danger. Elevated serum sodium and muscle weakness can occur in Cushing syndrome, but they do not warrant immediate attention compared to the potassium level and blood pressure in option A.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. 6.3% - This HbA1c level indicates good blood glucose control. It suggests that the client has been effectively managing their blood sugar levels over the past few months.
B. 7.86 - This is an atypical way of presenting HbA1c values. Typically, it is expressed as a percentage, so this value needs to be converted to be compared accurately.
C. 10% - This HbA1c level is elevated and indicates poor blood glucose control. It suggests that the client's blood sugar levels have been consistently high over the past few months.
D. 8.56% - This HbA1c level is elevated and indicates poor blood glucose control. It suggests that the client's blood sugar levels have been consistently high over the past few months.
Correct Answer is C
Explanation
A. Checking the pedal pulses is important for assessing circulation, but it may not directly address the cause of the muscle spasms. In this case, addressing the electrolyte imbalance is a higher priority.
B. Requesting a relaxant might provide temporary relief for muscle spasms, but it does not address the potential underlying cause. It's important to identify and treat the root issue.
C. Correct. Severe muscle spasms in a client post-thyroidectomy could indicate hypocalcemia, as the parathyroid glands, which regulate calcium levels, can be affected during the surgery. Verifying the most recent calcium level will help determine if this is the cause.
D. Administering an oral potassium supplement addresses a different electrolyte imbalance (hypokalemia), which is not typically associated with muscle spasms following a thyroidectomy. Calcium levels are more relevant in this context.
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