A nurse is caring for a client who has Cushing's syndrome. Which of the following interventions should the nurse expect to perform? (Select all that apply.)
Assess blood glucose level
Assess for neck vein distention
Weigh the client daily
Monitor for postural hypotension
Monitor for an irregular heart rate
Correct Answer : A,B,C,E
Rationale:
A. Assessing blood glucose levels is important because Cushing's syndrome can cause insulin resistance, leading to hyperglycemia.
B. Assessing for neck vein distention is necessary as it can indicate fluid overload, a common issue in Cushing's syndrome due to increased cortisol levels.
C. Weighing the client daily helps monitor for weight gain, which is a characteristic of Cushing's syndrome due to fat redistribution and fluid retention.
D. Monitoring for postural hypotension is less relevant in Cushing's syndrome; clients often experience hypertension rather than hypotension.
E. Monitoring for an irregular heart rate is important as electrolyte imbalances (like hypokalemia) associated with Cushing's can lead to cardiac arrhythmias.
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Correct Answer is C
Explanation
Rationale:
A. In hyperparathyroidism, calcium levels are typically increased due to excessive parathyroid hormone activity, leading to calcium mobilization from bones.
B. Parathyroid hormone levels would generally be increased in hyperparathyroidism as the parathyroid glands produce more hormone in response to low calcium levels, but the condition itself is defined by elevated hormone levels.
C. Increased phosphate levels are expected due to the effects of elevated parathyroid hormone causing increased renal excretion of phosphate while allowing calcium to rise.
D. Magnesium levels can vary, but they are not typically significantly elevated in hyperparathyroidism; thus, increased magnesium is not a standard finding.
Correct Answer is D
Explanation
Rationale:
A. Dorsal recumbent is not an ideal position after a thyroidectomy due to the risk of airway obstruction.
B. Supine position does not provide optimal airway protection post-surgery.
C. Sims' position is not recommended for clients recovering from a thyroidectomy as it could affect breathing and circulation.
D. Fowler’s position (head of the bed elevated 45 to 90 degrees) is the best position post-thyroidectomy to reduce tension on the suture line and to facilitate breathing by decreasing swelling around the surgical site.