A nurse is assessing a client with Cushing's syndrome. The nurse is aware that an exogenous cause of Cushing's syndrome is which of the following?
Insufficient insulin production
Long term use of glucocorticoids
Adrenal insufficiency
Overproduction of growth hormones
The Correct Answer is B
A. Insufficient insulin production is related to diabetes mellitus, not Cushing's syndrome.
B. Long-term use of glucocorticoids is a well-known exogenous cause of Cushing's syndrome, as it leads to excess cortisol in the body.
C. Adrenal insufficiency refers to a deficiency of adrenal hormones and would not cause Cushing's syndrome, which is characterized by excess hormones.
D. Overproduction of growth hormones is associated with acromegaly or gigantism, not Cushing's syndrome, which primarily involves excess cortisol.
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Correct Answer is A
Explanation
A. Encouraging fluid intake at and between meals helps to dilute urine and can reduce the risk of urinary tract infections (UTIs) by promoting regular urination.
B. Cleansing the perineum should be done from front to back to prevent the introduction of bacteria from the rectal area to the urethra, so this option is incorrect.
C. Offering the bedpan every 2 hours may not be sufficient for individuals at risk for UTIs, as more frequent voiding can help prevent infection.
D. An indwelling urinary catheter increases the risk of urinary tract infections and should be avoided unless absolutely necessary; intermittent catheterization is generally preferred for those with spinal cord injuries to minimize this risk.
Correct Answer is A
Explanation
A. Assessing respiratory status and airway patency is the highest priority in this situation due to the risk of respiratory compromise from cervical spinal cord injuries, which can affect the diaphragm and other respiratory muscles.
B. While assessing extremity strength and sensation is important, it comes after ensuring the client’s airway and breathing are stable.
C. Pain management is essential, but addressing immediate life-threatening conditions takes precedence over pain assessment.
D. Assessing the client's level of consciousness is crucial for overall evaluation but does not take priority over ensuring adequate respiratory function in the context of a cervical spinal cord injury.