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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is D
Explanation
Rationale:
A. An insufficient dose of insulin would likely cause hyperglycemia, not hypoglycemia.
B. Sugar substitutes do not affect blood glucose levels significantly and would not lead to hypoglycemia.
C. Birth control pills generally do not cause hypoglycemia.
D. Prolonged exercise increases insulin sensitivity and glucose uptake, which can lead to hypoglycemia if insulin or food intake is not adjusted accordingly. The 2-hour exercise session is the most likely cause of the hypoglycemic episode.
Correct Answer is D
Explanation
Rationale:
A. Toenail trimming should be performed by a professional to prevent injury, but it does not require immediate reporting.
B. Dark yellow urine can indicate dehydration, but it is not an urgent concern in this context.
C. Dizziness when standing is a concern, but it does not take priority over the refusal of breakfast, which may lead to hypoglycemia.
D. A refusal to eat can lead to hypoglycemia in clients with type 1 diabetes, and this situation should be reported immediately to prevent a dangerous drop in blood glucose levels.