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The nurse is caring for a client diagnosed with Cushing's Syndrome. Which of the following actions should be the nurse's highest priority?

A.

Implementing fall precautions

B.

Address client's coping mechanisms due to physical changes

C.

Teach client to avoid unnecessary exposure to others with infections

D.

Encouraging client to use incentive spirometer for improved lung expansion

Answer and Explanation

The Correct Answer is A

A. Clients with Cushing’s Syndrome often experience muscle weakness, osteoporosis, and a risk of fractures due to excess cortisol. Implementing fall precautions is the highest priority to prevent injury.  

 

B. Addressing coping mechanisms is important but not as immediate a safety concern as fall prevention.  

 

C. Avoiding infections is crucial due to immunosuppression from elevated cortisol; however, preventing falls remains a more immediate concern.  

 

D. Encouraging incentive spirometer use may support lung function, but it is not the highest priority compared to preventing falls.


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View Related questions

Correct Answer is B

Explanation

A. Serum thyroxine (T4) is typically decreased in primary hypothyroidism due to reduced thyroid hormone production.

B. In primary hypothyroidism, the thyroid gland fails to produce sufficient hormones, which leads to an increase in thyroid-stimulating hormone (TSH) as the pituitary gland tries to stimulate thyroid function. Elevated TSH is a common finding in primary hypothyroidism.

C. Serum T3 is usually decreased in primary hypothyroidism since the production of T3 and T4 is reduced.

D. Free T4 is typically low in primary hypothyroidism as the thyroid gland is underactive and not producing adequate levels of thyroid hormones.

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.

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