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 A
Explanation
Choice A Reason:
Elevate the head of the client's bed for 1 hr. after the feeding is appropriate. This action helps minimize the risk of aspiration. Elevating the head of the bed (typically at least 30 to 45 degrees) can reduce the chance of reflux and aspiration of the feeding solution into the lungs. This position should ideally be maintained for about 1 hour after the feeding to aid digestion and reduce the risk of complications.
Choice B Reason:
Administering the feeding solution at a cold temperature is inappropriate. Feeding solutions are generally administered at room temperature or slightly warmed to prevent discomfort and minimize the risk of altering the client's core body temperature. Cold temperatures can cause discomfort or cramping and might affect the absorption of the nutrients. Therefore, administering the feeding solution at a cold temperature is not recommended.
Choice C Reason:
Rotating the jejunostomy tube once per day is inappropriate. Rotating the jejunostomy tube is not typically part of routine care. Tube rotation can cause discomfort, irritation, and potential injury to the gastrointestinal tract. Tubes should be secured properly to prevent movement but not rotated unless specifically instructed by a healthcare provider for a particular reason, such as checking for proper tube placement.
Choice D Reason:
Flushing the tube with 90 ml of sterile water before and after the feeding is inappropriate.
Flushing the tube with sterile water before and after the feeding helps ensure the patency of the tube and prevents clogging. It's a standard procedure to clear the tube and maintain its function
Correct Answer is B
Explanation
Choice A Reason:
Administering enemas 2 days before the procedure. Enemas are not typically the primary method of bowel preparation for a colonoscopy. Healthcare providers often recommend specific bowel preparation solutions or laxatives that are more effective in thoroughly cleansing the colon.
Choice B Reason:
This is a standard bowel preparation instruction for colonoscopy to ensure a clear view of the colon during the procedure.
Choice C Reason:
This is not necessary for a colonoscopy. A clear liquid diet for a shorter period, usually 12-24 hours, is sufficient.
Choice D Reason:
Expect the provider to schedule another procedure to remove any polyps. While identifying and removing polyps is part of the objective of a colonoscopy, scheduling another procedure specifically for polyp removal isn't usually discussed beforehand. Polyp removal is often performed during the colonoscopy procedure if any are found.
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