Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?
Visible swelling of the neck, with no pain.
Warm, soft, moist, salmon-colored skin.
Husky voice and troubled by hoarseness.
Central type obesity, with thin extremities.
The Correct Answer is D
A. Visible swelling of the neck may indicate other conditions, such as thyroid issues, but it is not a characteristic finding of Cushing's syndrome.
B. Warm, soft, moist, salmon-colored skin is more indicative of hyperthyroidism rather than Cushing's syndrome, which typically presents with thin, fragile skin.
C. A husky voice and hoarseness can occur due to various reasons, but they are not classic symptoms of Cushing's syndrome.
D. Central type obesity, characterized by a rounded face and thin extremities, is a hallmark feature of Cushing's syndrome, caused by excessive cortisol levels leading to fat redistribution.
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Correct Answer is B
Explanation
A. Limiting oral fluid intake may be necessary in some cases of glomerulonephritis, especially if the client is experiencing edema or hypertension, but this is not a universal recommendation and should be assessed individually.
B. Restricting protein intake is important for clients with glomerulonephritis to reduce the workload on the kidneys and prevent further damage. This is a critical dietary adjustment that nurses should emphasize.
C. Increasing potassium-rich foods can be contraindicated in clients with glomerulonephritis, especially if renal function is compromised, as it can lead to hyperkalemia.
D. While high-fiber foods can be beneficial for overall health, they do not directly address the specific dietary needs of a client with glomerulonephritis in terms of protein and electrolyte balance.
Correct Answer is B
Explanation
A. While elevated creatinine and BUN are important indicators of kidney function, in the diuretic phase, the focus shifts to monitoring for complications, particularly fluid and electrolyte balance.
B. Hypovolemia can occur due to excessive diuresis during the diuretic phase, which can lead to significant cardiovascular effects, including ECG changes related to electrolyte imbalances, particularly potassium levels.
C. Monitoring for uremic irritation is important but less critical than monitoring for hypovolemia and ECG changes that can lead to acute complications.
D. While monitoring for side effects of TPN is relevant, it is not the priority in the context of AKI transitioning phases where fluid and electrolyte balance are paramount.