A nurse is caring for a client who has Cushing's syndrome. Which of the following interventions should the nurse expect to perform? (Select all that apply.)
Assess for neck vein distention
Monitor for postural hypotension
Assess blood glucose level
Monitor for an irregular heart rate
Weigh the client daily
Correct Answer : A,C,D,E
A. Assess for neck vein distention: Neck vein distention can occur in Cushing's syndrome due to fluid retention and hypertension. It is an important sign to monitor as it can indicate complications like heart failure.
B. Monitor for postural hypotension: Clients with Cushing's syndrome typically have hypertension rather than hypotension. Therefore, postural hypotension is not a common issue to monitor for in these patients.
C. Assess blood glucose level: Hyperglycemia is common in Cushing's syndrome due to increased cortisol levels, which promote glucose production and reduce glucose uptake by cells. Monitoring blood glucose is essential to manage this condition.
D. Monitor for an irregular heart rate: Cushing's syndrome can cause electrolyte imbalances (like hypokalemia), which may lead to cardiac arrhythmias, so monitoring for an irregular heart rate is important.
E. Weigh the client daily: Daily weight monitoring helps track fluid retention, which is common in Cushing's syndrome due to cortisol-induced fluid retention. This can help in managing the client’s fluid status and detecting worsening of symptoms.
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Related Questions
Correct Answer is B
Explanation
A. Helping the client select a low-salt diet: While a low-salt diet is important for managing conditions like hypertension and heart failure, it does not directly affect the viscosity of bronchial secretions in COPD.
B. Encouraging the client to drink 2 to 3 L of water daily: Increasing fluid intake helps to thin bronchial secretions, making them easier to expectorate. Adequate hydration is essential for patients with COPD to manage mucus and reduce the risk of respiratory infections.
C. Maintaining a semi-Fowler's position as often as possible: This position can help improve lung expansion and ease breathing but does not specifically help in loosening or thinning bronchial secretions.
D. Administering oxygen via nasal cannula at 2 L/min: Oxygen therapy is important for maintaining adequate oxygenation in COPD patients but does not address the issue of tenacious secretions directly.
Correct Answer is D
Explanation
A. Empyema: Empyema refers to the accumulation of pus in the pleural cavity, not a type of pneumonia. It is usually a complication of pneumonia rather than a description of the pneumonia itself.
B. Bronchopneumonia: Bronchopneumonia involves patchy consolidation that is usually scattered throughout the lung fields, not confined to a single lobe. It affects the bronchi and surrounding lung parenchyma.
C. Severe pneumonia: The term "severe pneumonia" describes the severity of the disease but does not specify the pattern of consolidation. It does not indicate whether the consolidation is lobar or patchy.
D. Lobar pneumonia: Lobar pneumonia is characterized by consolidation that involves an entire lobe of the lung. It typically presents with homogenous radiographic opacification of one or more lobes, often caused by pathogens such as Streptococcus pneumoniae.
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