A nurse is caring for a client with suspected pheochromocytoma. The nurse recognizes that which of the following is the priority action?
Obtain hourly glucose levels
Prepare client for a CT scan
Request order for serum calcium levels
Monitor Blood Pressure
The Correct Answer is D
A. Monitoring glucose levels may be necessary, as pheochromocytoma can cause hyperglycemia, but it is not the immediate priority.
B. A CT scan may be part of the diagnostic process to locate the adrenal tumor, but the priority is to control blood pressure first due to the risk of severe hypertensive crisis.
C. Serum calcium levels are not directly related to pheochromocytoma and are not a priority action.
D. Monitoring blood pressure is critical, as pheochromocytoma causes episodes of severe hypertension, which can lead to life-threatening complications.
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Correct Answer is B
Explanation
A. The Glasgow Coma Scale is useful for assessing consciousness levels but may not be as sensitive for changes in brainstem function in a patient already in an induced coma.
B. Assessing pupillary size and reaction provides critical information on brainstem function and can indicate changes in ICP. Changes in pupil size and reaction can signify worsening cerebral function or brain herniation.
C. Blood pressure and heart rate are vital signs that can suggest increased ICP, but they are not as direct an indicator of cerebral function as pupil assessment.
D. The gag reflex is important but does not provide as direct information about cerebral function related to ICP as pupillary assessment does.
Correct Answer is D
Explanation
A. Encouraging deep breathing exercises may help with respiratory function but does not address the immediate risks associated with increased ICP.
B. Elevating the head of the bed can help reduce ICP; however, the priority intervention is to closely monitor ICP to identify any changes in the client's condition.
C. Administering a sedative may be appropriate, but it is not as critical as monitoring ICP in a client with Cushing's Triad, where altered consciousness and respiratory changes may be present.
D. Monitoring ICP is crucial in this situation, as Cushing's Triad indicates a potential increase in ICP, and timely interventions can prevent further complications.