A nurse is collecting data from a client who has Cushing's syndrome. Which of the following findings should the nurse expect?
Jaundice
Muscle rigidity
Weight loss
Easily bruised
The Correct Answer is D
Choice A Reason:
Jaundice, characterized by yellowing of the skin and eyes, is typically associated with liver dysfunction or conditions affecting the breakdown of red blood cells, not directly linked to Cushing's syndrome. While some liver abnormalities can be seen in Cushing's syndrome due to metabolic changes, jaundice is not a typical manifestation of this condition.
Choice B Reason:
Muscle rigidity is more commonly associated with conditions like Parkinson's disease, dystonia, or certain muscle disorders. In Cushing's syndrome, muscle weakness due to protein breakdown and muscle wasting is a more expected finding rather than muscle rigidity.
Choice C Reason:
Weight loss is incorrect. Weight gain, particularly in the central part of the body (trunk) and face (creating a "moon face"), is a more common characteristic of Cushing's syndrome. The excess cortisol often leads to increased fat deposits, especially in these areas, rather than weight loss.
Cushing's syndrome is characterized by an excess of cortisol in the body, either due to the body producing too much cortisol or from long-term use of corticosteroid medications. Considering this condition, the nurse should expect the following finding:
Choice D Reason:
Easily bruised is correct. Excess cortisol can lead to the thinning of the skin and weakening of blood vessels, making individuals with Cushing's syndrome prone to easy bruising. Other common findings associated with Cushing's syndrome include weight gain (especially in the trunk and face), muscle weakness, high blood pressure, fatigue, and changes in skin such as thinning and purple stretch marks.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Informing the client of the adverse effect of diarrhea is less common with clonidine use, especially in comparison to other side effects like dry mouth or skin irritation.
Choice B Reason:
Monitoring for weight loss isn't a primary concern specifically associated with transdermal clonidine use.
Choice C Reason:
Advise the client about increased dry mouth. Dry mouth is a common adverse effect of clonidine, including the transdermal form. Patients should be informed about this so they can manage it effectively, for example, by drinking plenty of water or using sugar-free gum or candy to stimulate saliva production.
Choice D Reason:
Hypopigmentation is not a commonly reported issue with transdermal clonidine patches. However, local skin irritation or rash can occur at the site of the patch.
Correct Answer is D
Explanation
Choice A Reason:
Preparing the sterile dressing supplies 30 min before the dressing change is correct. While it's crucial to have all supplies ready before starting the procedure, preparing them 30 minutes in advance might not align with the principles of maintaining sterility. It's generally best to prepare sterile supplies just before the procedure to minimize the risk of contamination.
Choice B Reason:
Don sterile gloves before removing the dressing is incorrect. Sterile gloves should indeed be worn during the dressing change, but they should be put on after removing the old dressing. This ensures that the clean gloves don't touch potentially contaminated surfaces during the removal of the old dressing.
Choice C Reason:
Disinfect the wound bed with alcohol before applying tape is incorrect. Using alcohol to disinfect the wound bed is not recommended as it can cause tissue irritation and delay wound healing. Sterile saline or another wound cleansing solution prescribed for wound care would be more appropriate to clean the wound bed. Additionally, applying tape directly to the wound is generally avoided to prevent further damage to the fragile tissues of a pressure ulcer.
Choice D Reason:
Offering the client pain medication before the procedure is correct. Providing pain medication before the procedure ensures the client's comfort and helps manage any discomfort or pain associated with the dressing change, particularly when dealing with a stage III pressure ulcer, which can be quite sensitive.
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