The nurse is caring for a patient who has nausea and vomiting. Which assessment data should be of most concern to the nurse?

Urine output of 30 mL/hr

Blood pressure is 90/40

IV site is infiltrated

Oral fluid intake of 100 mL for 8 hours

Answer and Explanation

The Correct Answer is B

Choice A reason: Urine output of 30 mL/hr is concerning as it is on the lower end of normal and can indicate dehydration or impaired renal function. However, in this context, it is less immediately alarming compared to severely low blood pressure.

Choice B reason: Blood pressure of 90/40 is critically low and indicates hypotension, which can be a sign of severe dehydration or shock, especially in a patient with ongoing nausea and vomiting. This requires immediate attention and intervention to stabilize the patient and prevent further complications.

Choice C reason: An infiltrated IV site is a problem that needs to be addressed to ensure proper administration of fluids and medications. However, it is not as immediately life-threatening as hypotension.

Choice D reason: Oral fluid intake of 100 mL for 8 hours is inadequate, suggesting that the patient may be dehydrated. While concerning, it is not as acutely critical as low blood pressure, which directly affects perfusion and organ function.

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Correct Answer is ["B","C","D"]

Explanation

Choice A reason: Anorexia, nausea, and vomiting are not typical findings associated with Cushing syndrome. These symptoms can be related to other medical conditions but do not specifically indicate Cushing syndrome.

Choice B reason: Truncal obesity, thin extremities, and rounding of the face (moon face) are classic signs of Cushing syndrome. This condition leads to fat redistribution, resulting in increased fat around the trunk and face while the extremities appear thinner. The distinctive appearance of moon face is due to fat accumulation.

Choice C reason: Purplish streaks on the abdomen, also known as striae, are a common feature of Cushing syndrome. These stretch marks occur due to the excessive production of cortisol, which weakens the connective tissue, leading to skin changes.

Choice D reason: Hyperglycemia, or high blood sugar, is frequently seen in patients with Cushing syndrome. The excess cortisol increases glucose production and decreases insulin sensitivity, leading to elevated blood sugar levels.

Choice E reason: A bronzed appearance of the skin is not a typical finding of Cushing syndrome. This symptom is more commonly associated with Addison's disease, which involves adrenal insufficiency rather than excess cortisol production seen in Cushing syndrome.

A. Place the patient in restraints for safety B. Insert an NGT C. Anticipate thrombolytic therapy for ischemic stroke D. Establish IV access with normal saline E. Place the patient in the prone position

Correct Answer is ["C","D"]

Explanation

Choice A reason: Placing the patient in restraints for safety is not typically necessary unless the patient is agitated or a danger to themselves or others. This action is not directly addressing the acute condition of a stroke.

Choice B reason: Inserting an NGT (nasogastric tube) is not an immediate priority in the acute management of a stroke. This might be considered later if the patient has swallowing difficulties and needs nutritional support, but it is not a first-line intervention.

Choice C reason: Anticipating thrombolytic therapy for ischemic stroke is appropriate, as timely administration of thrombolytics can dissolve the clot and improve blood flow to the affected brain area, potentially reducing the severity of the stroke.

Choice D reason: Establishing IV access with normal saline is crucial for administering medications and maintaining hydration. It ensures that the patient can receive necessary interventions promptly.

Choice E reason: Placing the patient in the prone position is not appropriate in the management of an acute stroke. The prone position is generally used in respiratory conditions to improve oxygenation but is not relevant to stroke management.

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The nurse is caring for a patient who has nausea and vomiting. Which assessment data should be of most concern to the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is being admitted with a diagnosis of Cushing syndrome. Which three findings will the nurse expect during the assessment?

Correct Answer is ["B","C","D"]

Explanation

Correct Answer is ["C","D"]

Explanation

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