Which admission assessment findings should the nurse document related to a client who has been diagnosed with Cushing’s syndrome?

Choice A reason: Calculating gestation from last menstrual cycle is not a reliable way to determine if the client is pregnant, and it is not an urgent intervention that the nurse should implement immediately. The last menstrual cycle may not reflect the actual date of conception, and it may vary depending on the client's cycle length, ovulation time, and other factors. The nurse should use a more accurate and objective method to confirm or rule out pregnancy, such as a urine or blood test.

Choice B reason: Continuing with surgery as scheduled is not a safe or ethical intervention that the nurse should implement immediately, without verifying the client's pregnancy status. Surgery, especially abdominal surgery, can pose significant risks to the client and the fetus, such as bleeding, infection, anesthesia complications, preterm labor, and miscarriage. The nurse should inform the surgical team about the possibility of pregnancy and obtain the client's informed consent before proceeding with surgery.

Choice C reason: Performing a bedside pregnancy test is the most appropriate and timely intervention that the nurse should implement immediately, given the client's situation. A bedside pregnancy test is a simple and quick way to detect the presence of human chorionic gonadotropin (hCG), a hormone produced by the placenta, in the client's urine. A positive result indicates that the client is pregnant, and a negative result indicates that the client is not pregnant. The nurse should perform the test as soon as possible and report the result to the surgical team and the client.

Choice D reason: Notifying the surgical team to cancel the surgery is not a necessary or prudent intervention that the nurse should implement immediately, without confirming the client's pregnancy status. Canceling the surgery may delay the treatment of the client's acute appendicitis, which can lead to serious complications, such as perforation, abscess, peritonitis, and sepsis. The nurse should first perform a bedside pregnancy test and then discuss the risks and benefits of surgery with the surgical team and the client.

Choice A reason: Cleaning the tongue and mouth with swabs is not the best initial nursing action, as it can cause more irritation and pain to the mucous membranes. Swabs can be abrasive and harsh on the inflamed and ulcerated tissues. The client should use a soft toothbrush or a sponge to gently clean the tongue and mouth, and avoid alcohol-based mouthwashes or rinses.

Choice B reason: Administering a topical analgesic is appropriate if the client is experiencing significant pain, but this is a secondary intervention. Pain management is important, but preventing worsening of mucositis through routine care is the priority.

Choice C reason: Obtaining a soft diet for the client is a correct nursing action, but not the best initial one, as it can help prevent further trauma and damage to the mucous membranes. A soft diet consists of foods that are easy to chew and swallow, such as soups, puddings, yogurts, and mashed potatoes. The client should avoid foods that are spicy, acidic, salty, or hard, such as citrus fruits, tomatoes, chips, and nuts.

Choice D reason: Encouraging frequent mouth care is the best initial action. Regular, gentle oral hygiene reduces bacterial load, soothes irritation, prevents secondary infection, and promotes healing of mucosal tissues affected by chemotherapy. It also empowers the client to take an active role in managing their condition.