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 C
Explanation
Rationale:
A. Drinking fluids is important to prevent dehydration, but it is not the priority over monitoring blood glucose levels.
B. Consuming carbohydrates is necessary to prevent hypoglycemia, but this is not the primary concern during illness.
C. Monitoring blood glucose levels every 4 hours is the priority action because blood glucose can fluctuate significantly during illness, increasing the risk of hyperglycemia or diabetic ketoacidosis.
D. Taking the usual insulin dosage is essential, but it should be based on frequent glucose monitoring to adjust for illness-related changes in insulin requirements.
Correct Answer is A
Explanation
Rationale:
A. Airway patency is the priority concern following a thyroidectomy due to the risk of swelling or bleeding that can compress the airway, leading to respiratory compromise.
B. Hoarseness can occur due to laryngeal nerve irritation but is not the priority over airway concerns.
C. Pain control is important but is not the primary priority compared to maintaining a patent airway.
D. Visual deficits are not typically related to postoperative thyroidectomy care.