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 an irregular heart rate.
Assess blood glucose level.
Monitor for postural hypotension.
Weigh the client daily.
Correct Answer : A,B,C,D,E
Choice A rationale
Assessing for neck vein distention helps monitor fluid overload, which is common in Cushing's syndrome due to cortisol's effects on fluid retention.
Choice B rationale
Monitoring for an irregular heart rate is important because cortisol can cause electrolyte imbalances and hypertension, which may affect heart rhythm.
Choice C rationale
Assessing blood glucose levels is essential since Cushing's syndrome can cause hyperglycemia due to cortisol's effects on glucose metabolism.
Choice D rationale
Monitoring for postural hypotension helps manage potential complications from cortisol's effects on blood pressure regulation.
Choice E rationale
Weighing the client daily is important for monitoring fluid retention and weight changes associated with Cushing's syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Liver cancer is not associated with elevated prostate specific antigen (PSA) levels. PSA is a protein produced primarily by prostate cells, and its elevation is typically linked to prostate-related conditions rather than liver disorders.
Choice B rationale
Breast cancer is not associated with elevated PSA levels. PSA is specific to prostate cells, which are not present in breast tissue. Therefore, PSA is not a marker used in diagnosing or monitoring breast cancer.
Choice C rationale
Colon cancer is not linked to elevated PSA levels. PSA is not a biomarker for colon cancer, as it is specific to the prostate gland. Other markers, such as carcinoembryonic antigen (CEA), are more relevant for colon cancer.
Choice D rationale
Prostatic cancer is associated with elevated PSA levels. PSA is produced by prostate cells, and elevated levels can indicate prostate cancer, benign prostatic hyperplasia (BPH), or inflammation of the prostate.
Correct Answer is B
Explanation
Choice A rationale
Hyperactive deep tendon reflexes are not associated with thrombocytopenia (low platelet count). Thrombocytopenia primarily affects bleeding and clotting functions rather than neuromuscular reflexes.
Choice B rationale
Spontaneous bleeding is a significant risk with a platelet count of 9,000/mm³, which is critically low. Platelets are essential for blood clotting, and severe thrombocytopenia increases the risk of spontaneous bleeding.
Choice C rationale
Oliguria, or decreased urine output, is not directly related to thrombocytopenia. It may be associated with kidney function issues, but it is not a consequence of low platelet counts.
Choice D rationale
Infection is not directly related to a low platelet count. While patients with severe thrombocytopenia may be at risk for bleeding complications, their susceptibility to infections is more related to their white blood cell counts and immune function.
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