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 D
Explanation
A. Encouraging deep breathing exercises may help with respiratory function but does not address the immediate risks associated with increased ICP.
B. Elevating the head of the bed can help reduce ICP; however, the priority intervention is to closely monitor ICP to identify any changes in the client's condition.
C. Administering a sedative may be appropriate, but it is not as critical as monitoring ICP in a client with Cushing's Triad, where altered consciousness and respiratory changes may be present.
D. Monitoring ICP is crucial in this situation, as Cushing's Triad indicates a potential increase in ICP, and timely interventions can prevent further complications.