The nurse is developing the plan of care for a client diagnosed with Cushing’s syndrome and identifies that the client’s risk factors include poor wound healing, decreased bone density, and increased capillary fragility.
Which outcome statement should the nurse include in the plan of care?

Client implements measures to prevent injury.

Client describes ways to control disease.

Client demonstrates improved body image.

Client experiences a normal fluid balance.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Given the client’s risk factors of poor wound healing, decreased bone density, and increased capillary fragility, the most appropriate outcome statement to include in the plan of care is that the client implements measures to prevent injury. This includes avoiding falls, using caution with sharp objects to prevent cuts, and taking steps to protect the bones.
Choice B rationale
While it is important for the client to understand their disease and ways to control it, this is not the most appropriate outcome statement given the client’s specific risk factors.
Choice C rationale
Improving body image may be a relevant goal for some clients with Cushing’s syndrome, but it is not the most appropriate outcome statement given the client’s specific risk factors.
Choice D rationale
Experiencing a normal fluid balance may be a relevant goal for some clients with Cushing’s syndrome, but it is not the most appropriate outcome statement given the client’s specific risk factors.

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Free Nursing Study Resources

Correct Answer is ["B","C","E"]

Explanation

Clinical Rationale

Choice B (Correct): To ensure a proper seal and maintain the prescribed $FiO_2$, the mask must be secured over the bridge of the nose first, then pulled down to cover the mouth and chin. A snug fit prevents oxygen from leaking toward the eyes, which can cause irritation, and ensures the client receives the full benefit of the oxygen therapy.

Choice A (Incorrect): Simple face masks used in acute care are generally disposable, single-patient-use items. Cleaning them with soap and water is not standard practice and could introduce contaminants or moisture that compromises the equipment.

Choice C (Incorrect): A client with an oxygen saturation of 89% is hypoxic and requires continuous supplemental oxygen. Taking frequent "breaks" would cause the saturation to drop further, potentially leading to respiratory distress or cardiac strain.

Choice D (Incorrect): For an oxygen mask to be effective, it must cover both the nose and the mouth. Leaving the nose exposed allows the client to inhale room air (21% oxygen), which dilutes the supplemental oxygen and fails to reach the desired therapeutic level.

Choice E (Incorrect): Oxygen is a medication that requires a provider's order. While a nurse may titrate oxygen based on specific standing orders (e.g., "titrate to keep $SpO_2$ > 92%"), a nurse cannot unilaterally "adjust" levels without a protocol or direct order in place.

A. How do you cope with the voices? B. When do you hear the voices? C. Which medication works best for you? D. What are the voices saying?

Correct Answer is D

Explanation

Choice A rationale

While it is essential to assess how the client copes with auditory hallucinations, asking this question alone does not provide specific information about the content of the hallucinations.

Choice B rationale

The timing of the voices can provide some insight into the triggers or patterns of the hallucinations, but it does not directly address the content or potential impact of the hallucinations on the client’s behavior or mental state.

Choice C rationale

While medication efficacy is an important aspect of managing schizophrenia, it does not directly address the current experience of the client’s hallucinations.

Choice D rationale

Understanding what the voices are saying to the client can provide critical information about potential risks, including self-harm or harm to others, and can guide the treatment plan. This is why it is the most important question for the nurse to include in the client’s assessment.

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The nurse is developing the plan of care for a client diagnosed with Cushing’s syndrome and identifies that the client’s risk factors include poor wound healing, decreased bone density, and increased capillary fragility. Which outcome statement should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C","E"]

Explanation

Clinical Rationale

A client with schizophrenia is admitted to the hospital reporting auditory hallucinations. Which query is most important for the nurse to include in the client’s assessment?

Correct Answer is D

Explanation

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The nurse is developing the plan of care for a client diagnosed with Cushing’s syndrome and identifies that the client’s risk factors include poor wound healing, decreased bone density, and increased capillary fragility.
Which outcome statement should the nurse include in the plan of care?