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. The supine position can increase ICP and is not recommended for clients with elevated ICP.
B. Instructing the client to pull themselves up may increase ICP due to straining.
C. Log rolling helps maintain spinal alignment and minimizes abrupt head movement, which is essential in managing ICP.
D. Sitting with legs dangling may cause a sudden shift in intracranial pressure and is not advised for these clients.
Correct Answer is C
Explanation
A. Bradycardia is not a common finding in diabetes insipidus; rather, patients may experience tachycardia due to volume depletion.
B. Bounding peripheral pulses may occur in conditions with fluid overload, which is not typical in diabetes insipidus where there is a lack of fluid retention.
C. Urine specific gravity of 1.002 indicates dilute urine, which is consistent with diabetes insipidus, where the body fails to concentrate urine due to insufficient antidiuretic hormone (ADH).
D. Clients with diabetes insipidus typically experience polyuria, resulting in increased urine output rather than normal levels