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 A
Explanation
A. Mastoiditis often results in inflammation and infection that extend to the middle ear, causing the tympanic membrane to appear red, dull, thickened, and immobile upon examination.
B. A transparent and clear tympanic membrane is typical in a healthy ear, not in cases of mastoiditis.
C. A pearly colored tympanic membrane is also indicative of a normal, healthy ear without infection.
D. A pink-colored tympanic membrane may suggest mild irritation but is not a characteristic finding of mastoiditis.
Correct Answer is A
Explanation
A. Elevated PTH levels lead to increased calcium reabsorption from bones and enhanced calcium absorption in the kidneys, which can result in hypercalcemia and increase the risk of renal calculi (kidney stones).
B. Irritability and anxiety are not directly associated with high PTH levels. They are more often linked to thyroid hormone imbalances.
C. Frequent diarrhea is not a common symptom of elevated PTH levels; instead, hypercalcemia can lead to constipation.
D. Tetany and muscle pain are more commonly associated with low calcium levels, such as in hypoparathyroidism, not elevated PTH.