A nurse is caring for a client with Cushing's syndrome. Which assessment findings would the nurse expect? (Select all that apply.)
Purple striae
Moon face
Bronze pigmentation
Buffalo hump
Poor wound healing
Correct Answer : A,B,D,E
Rationale:
A. Purple striae (stretch marks) are common in Cushing's syndrome due to skin thinning and the redistribution of fat.
B. A "moon face" is a classic sign of Cushing's syndrome, caused by fat deposition in the face.
C. Bronze pigmentation is associated with Addison's disease, not Cushing's syndrome.
D. A "buffalo hump," or fat accumulation on the upper back, is another characteristic feature of Cushing's syndrome.
E. Poor wound healing is expected in Cushing's syndrome due to the effects of prolonged exposure to high cortisol levels, which impair immune function and tissue repair.
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Correct Answer is D
Explanation
Rationale:
A. Fluid intake may need to be monitored, but restricting fluids is not typically advised unless specifically directed by the healthcare provider due to complications like diabetes insipidus.
B. Avoiding deep breathing exercises is not recommended, as these exercises are important for preventing respiratory complications postoperatively.
C. Lying flat for 48 hours after surgery is incorrect; the head of the bed is usually elevated to decrease intracranial pressure and promote healing.
D. Avoiding blowing the nose and bending at the waist is crucial after transsphenoidal hypophysectomy to prevent increased intracranial pressure and avoid disrupting the surgical site, which could lead to complications such as cerebrospinal fluid leakage.
Correct Answer is D
Explanation
Rationale:
A. Adjusting the rate of the bladder irrigation might be necessary, but it is not the first action to take when there is no drainage.
B. Ambulating the client can help promote bladder function, but it is not the immediate priority when assessing catheter function.
C. Notifying the provider is important if the issue cannot be resolved, but the nurse should first attempt to resolve common, simple issues like a kinked tube.
D. Checking the tubing for kinks is the most immediate and logical first action to take. Kinks in the tubing can obstruct urine flow, and correcting this can often resolve the issue without further intervention.