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 D
Explanation
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.
Correct Answer is D
Explanation
A. Exophthalmos is typically associated with hyperthyroidism (specifically Graves' disease) rather than hypothyroidism.
B. Diaphoresis (excessive sweating) is also more common in hyperthyroid states, not hypothyroidism.
C. Palpitations are indicative of an increased metabolic rate, which is common in hyperthyroidism; therefore, they would not be expected in a client with hypothyroidism.
D. Lethargy is a classic symptom of hypothyroidism due to decreased metabolism, leading to fatigue and reduced energy levels, making it the expected finding.