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 D
Explanation
A. While noting the time of day is important for documentation, it does not address the immediate concern of elevated intraocular pressure (IOP).
B. Applying normal saline drops is not indicated in the immediate management of elevated IOP in glaucoma; it does not directly affect IOP levels.
C. Instructing the client to sleep with the head of the bed flat is not advisable, as elevated head positions may help decrease IOP.
D. An IOP of 23 mm Hg is above the normal range (10-21 mm Hg) and indicates potential glaucoma. Therefore, contacting the primary health care provider for further evaluation and treatment is the most appropriate initial action.
Correct Answer is C
Explanation
A. While pain level assessment is important, it is not the priority immediately after a significant brain injury where neurological changes may occur.
B. Wound site assessment is also essential but does not take precedence over neurological assessment in this context.
C. A neurological assessment is the priority to identify any changes in the client's condition that may indicate complications such as increased intracranial pressure, which can occur after brain surgery.
D. Respiratory status assessment is important but is usually addressed through monitoring and interventions related to neurological function, as brain injuries can affect respiratory drive and function.