A nurse is caring for a client with a pheochromocytoma. Which assessment finding will the nurse expect for this client?
Decreased pulse
Elevated blood pressure
Cold intolerance
Decreased respiratory rate
The Correct Answer is B
Rationale:
A. A decreased pulse is not typically associated with pheochromocytoma. This condition is characterized by the excessive release of catecholamines, which usually leads to an increased heart rate.
B. Pheochromocytoma is a tumor of the adrenal medulla that causes excessive secretion of catecholamines, leading to episodic or sustained hypertension. Elevated blood pressure is a hallmark symptom of this condition.
C. Cold intolerance is more commonly associated with hypothyroidism and is not a typical finding in pheochromocytoma.
D. Decreased respiratory rate is not characteristic of pheochromocytoma; instead, clients may experience symptoms such as palpitations, sweating, and headaches due to the elevated catecholamine levels.
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Correct Answer is C
Explanation
Rationale:
A. Limiting walking episodes may reduce discomfort but does not address the underlying issue or potential complications.
B. While leg cramps can be common during pregnancy, calf pain could also indicate a more serious condition, such as deep vein thrombosis (DVT), and should not be dismissed as normal without further investigation.
C. Gathering further assessment data is crucial to determine the cause of the calf pain, as it may indicate DVT, a potentially life-threatening condition. The nurse should assess for other symptoms like swelling, redness, or warmth in the leg.
D. Instructing the client to elevate the legs may be appropriate for general discomfort, but without proper assessment, it may not be the correct intervention if DVT is present.
Correct Answer is D
Explanation
Rationale:
A. Hypertension can be a symptom of many conditions and is not specific to HHS.
B. Fruity breath is typically associated with diabetic ketoacidosis (DKA) due to the presence of acetone, not HHS.
C. Ketosis is a key feature of DKA, not HHS. In HHS, ketosis is usually absent or minimal.
D. A glucose level of 650 mg/dL is indicative of HHS, which is characterized by extremely high blood glucose levels without significant ketosis. HHS often occurs in type 2 diabetes and is marked by severe hyperglycemia, dehydration, and altered mental status.