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. Quadriplegia, or tetraplegia, is typically associated with injuries at or above the C4 level, not T2-T3.
B. A T2-T3 spinal cord injury can lead to loss of sensation and motor function below the level of injury, affecting the thoracic region and lower body.
C. Hemiplegia, which refers to paralysis on one side of the body, is typically due to brain injuries or strokes, not spinal cord injuries.
D. While bladder control may be affected, the most direct impact of T2-T3 injury is the loss of sensation and motor function below that level.
Correct Answer is ["A","C","D"]
Explanation
A. Elevating the head of the bed to 30-45 degrees helps facilitate venous drainage from the brain, thereby reducing ICP.
B. Administering intravenous fluids rapidly is not appropriate, as it can lead to fluid overload and increase ICP.
C. Keeping the client in a calm and quiet environment minimizes stimulation, which can contribute to increased ICP.
D. Administering morphine sulfate as prescribed can provide pain relief, which may help decrease ICP since pain can contribute to increased intracranial pressure.
E. The Valsalva maneuver increases intrathoracic pressure and can lead to increased ICP, making it contraindicated in this scenario.