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 C
Explanation
A. Pitting edema: Pitting edema is more indicative of fluid retention, often associated with heart failure itself, rather than a direct sign of hypokalemia.
B. Dyspnea: Dyspnea is typically a symptom of fluid overload or respiratory conditions and is not a specific indicator of hypokalemia.
C. Fatigue: Fatigue is a common symptom of hypokalemia because low potassium levels affect muscle function and overall energy levels. It is a key indicator of electrolyte imbalance.
D. Oliguria: Oliguria, or decreased urine output, is more associated with kidney function issues or severe dehydration, not directly with hypokalemia.
Correct Answer is D
Explanation
A. Hypotension: Hypotension is not a typical sign of hypoxemia during an asthma attack. Hypoxemia primarily affects the respiratory and central nervous systems rather than causing direct cardiovascular symptoms like low blood pressure.
B. Nausea: Nausea is not a common manifestation of hypoxemia during an asthma attack. It can occur in many different conditions but is not specifically related to hypoxemia or asthma.
C. Dysphagia: Dysphagia, or difficulty swallowing, is unrelated to hypoxemia and asthma. It is typically associated with conditions affecting the esophagus or throat.
D. Agitation: Agitation is a common manifestation of hypoxemia because low oxygen levels in the blood can affect brain function, leading to anxiety, restlessness, and agitation. During an asthma attack, inadequate oxygenation can cause significant distress and changes in mental status.
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