The nurse providing care for a client with Cushing syndrome has identified the nursing diagnosis of risk for injury related to weakness. How should the nurse best reduce this risk?

Provide constant supervision

Establish fall-prevention measures

Encourage bed rest whenever possible

Encourage the use of assistive devices

Answer and Explanation

The Correct Answer is B

Reasoning:

Choice A reason: Constant supervision is impractical and not the most effective way to reduce fall risk in Cushing syndrome. While supervision can help, it does not address environmental hazards or promote independence. Muscle weakness from corticosteroid-induced myopathy increases fall risk, making targeted prevention strategies more practical and effective.

Choice B reason: Fall-prevention measures, such as removing obstacles, ensuring adequate lighting, and using non-slip mats, directly address the risk of injury from muscle weakness in Cushing syndrome. These measures reduce environmental hazards and promote safety, effectively mitigating the risk of falls due to corticosteroid-induced myopathy and osteoporosis.

Choice C reason: Encouraging bed rest increases the risk of complications like muscle atrophy and thromboembolism in Cushing syndrome. Prolonged immobility exacerbates muscle weakness and bone loss, both already worsened by corticosteroids, making bed rest counterproductive to maintaining strength and reducing injury risk from falls.

Choice D reason: Assistive devices like canes or walkers can help, but they are not the primary strategy. Fall-prevention measures address environmental risks broadly, benefiting all patients with weakness. Devices are useful for severe mobility issues but are less comprehensive than environmental modifications for preventing falls in Cushing syndrome.

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Correct Answer is B

Explanation

Reasoning:

Choice A reason: Taking iron with meals reduces gastrointestinal upset but does not prevent tooth staining. Food may decrease iron absorption by binding to dietary components, but it has no direct effect on preventing contact between liquid iron preparations and teeth, which causes staining.

Choice B reason: Diluting liquid iron preparations with juice and drinking through a straw minimizes contact with teeth, preventing staining. Iron can bind to enamel, causing discoloration, and using a straw directs the solution past the teeth, reducing exposure while juice dilutes the concentration, protecting dental health.

Choice C reason: Avoiding combining iron with other medications prevents absorption interactions but does not address tooth staining. Certain drugs, like tetracycline, may interact with iron, but this is unrelated to the enamel discoloration caused by direct contact with liquid iron preparations.

Choice D reason: Avoiding antacids with iron prevents reduced absorption, as antacids increase gastric pH, impairing iron solubility. However, this does not prevent tooth staining, which occurs from direct contact of liquid iron with enamel, making this action irrelevant to the goal of dental protection.

A. Normal hematocrit B. Low hematocrit C. High hematocrit D. Normal blood smear

Correct Answer is B

Explanation

Reasoning:

Choice A reason: Normal hematocrit is not typical in sickle cell anemia, a hemolytic disorder where red blood cells are destroyed prematurely due to abnormal hemoglobin (HbS). Chronic hemolysis reduces red blood cell mass, lowering hematocrit, making a normal value inconsistent with the disease’s pathophysiology.

Choice B reason: Low hematocrit is characteristic of sickle cell anemia due to chronic hemolysis. Sickled red blood cells have a shorter lifespan, reducing circulating red blood cells and hemoglobin, resulting in a decreased hematocrit. This reflects the anemia’s impact on oxygen-carrying capacity, a hallmark of the condition.

Choice C reason: High hematocrit is not associated with sickle cell anemia. Elevated hematocrit occurs in conditions like polycythemia, where red blood cell mass increases. Sickle cell anemia causes hemolysis, reducing red blood cells and hematocrit, making a high value inconsistent with the disease.

Choice D reason: A normal blood smear is not expected in sickle cell anemia. Blood smears show sickled red blood cells, anisocytosis, and poikilocytosis due to hemoglobin S polymerization. These abnormal findings contrast with a normal smear, which would not reflect the hemolytic and morphological changes of the disease.

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The nurse providing care for a client with Cushing syndrome has identified the nursing diagnosis of risk for injury related to weakness. How should the nurse best reduce this risk?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse should advise a client with iron deficiency anemia to take which action to prevent staining of the teeth?

Correct Answer is B

Explanation

A client with sickle cell anemia has a:

Correct Answer is B

Explanation

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