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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
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.
Correct Answer is C
Explanation
A. Increased pulmonary artery wedge pressure (PAWP): PAWP measures left atrial pressure, which is typically increased in left-sided heart failure, not right-sided. Right-sided heart failure leads to systemic congestion rather than pulmonary congestion.
B. Decreased specific gravity: Specific gravity measures urine concentration. It is not a primary indicator of heart failure. Heart failure usually affects fluid balance rather than specific urine concentration.
C. Elevated central venous pressure (CVP): CVP reflects the pressure in the right atrium and central veins, which is elevated in right-sided heart failure due to the backup of blood in the systemic circulation. This results in increased venous pressure.
D. Decreased brain natriuretic peptide (BNP): BNP levels are typically elevated in heart failure, as they reflect the degree of ventricular stretching and fluid overload. A decrease would not be expected in acute heart failure.
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