The nurse is caring for a client diagnosed with Cushing's Syndrome. Which of the following actions should be the nurse's highest priority?
Implementing fall precautions
Address client's coping mechanisms due to physical changes
Teach client to avoid unnecessary exposure to others with infections
Encouraging client to use incentive spirometer for improved lung expansion
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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Correct Answer is C
Explanation
A. While chlorine can kill some bacteria, it does not prevent all microbial growth and does not directly explain ear infections.
B. Pool water entering the Eustachian tubes is unlikely; infections are more commonly related to pathogens in the water.
C. The best response addresses the presence of microorganisms in pool water that can enter the ear and potentially lead to infections, such as swimmer's ear (otitis externa).
D. Pool water is not typically associated with drying out the ears; rather, it can lead to excess moisture, which can promote bacterial growth.
Correct Answer is C
Explanation
A. While ensuring proper alignment is important, it does not address the existing skin breakdown and irritation.
B. Applying zinc oxide cream may not be appropriate as it can trap moisture, potentially worsening the skin condition around pin sites.
C. Padding the areas of skin breakdown with foam dressing is an appropriate intervention as it can provide cushioning, reduce friction, and protect the skin from further injury.
D. Loosening the halo device could compromise the stabilization it provides and may not effectively address skin integrity issues.