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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Correct Answer is ["A","F"]

Explanation

Choice A rationale

Stabilizing the cervical spine is one of the first actions that should be taken during the primary survey of a trauma patient. This is to prevent any potential injury to the spinal cord, which could result in permanent paralysis.

Choice B rationale
Checking for a pulse is an important part of the primary survey, but it is not one of the first actions that should be taken. The first priority is to ensure that the airway is patent and the cervical spine is stabilized.

Choice C rationale
Requesting an x-ray is not one of the first actions that should be taken during the primary survey. The first priority is to assess the client’s airway, breathing, and circulation, and to stabilize the cervical spine.

Choice D rationale
Assessing the respiratory rate is an important part of the primary survey, but it is not one of the first actions that should be taken. The first priority is to ensure that the airway is patent and the cervical spine is stabilized.

Choice E rationale
Examining the abdomen is an important part of the secondary survey, which is conducted after the primary survey. The first priority during the primary survey is to assess the client’s airway, breathing, and circulation, and to stabilize the cervical spine.
Choice F rationale

Ensuring that the airway is patent is one of the first actions that should be taken during the primary survey. This is to ensure that the client is able to breathe effectively and receive adequate oxygenation.

A. Obtain equipment for gastric lavage. B. Determine the type of chemical exposure. C. Assess the child for altered sensorium. D. Call the poison control emergency number.

Correct Answer is B

Explanation

Choice A rationale
Gastric lavage is a procedure that involves the insertion of a tube into the stomach to remove its contents and is typically used in cases of poisoning or drug overdose. However, it should not be the first action taken. The type of chemical exposure needs to be determined first to guide appropriate treatment.
Choice B rationale
Determining the type of chemical exposure is crucial as it guides the subsequent steps in management. Different chemicals can have different effects on the body and require different treatments.
Choice C rationale
While assessing for altered sensorium is important in a child exposed to chemicals, it is not the first action. The nurse needs to identify the type of chemical the child was exposed to in order to anticipate potential complications and guide treatment.
Choice D rationale

Calling the poison control emergency number is an important step in managing a case of chemical exposure. However, having information about the type of chemical the child was exposed to can make this call more effective.

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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?

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Naxlex Comprehensive Predictor Exams

The client is a 26-year-old female who fell from an apartment balcony. She was transported to the hospital via ambulance. The client enters the emergency room on a stretcher and is met in the trauma bay by the nurse. What two actions should the nurse take first during the primary survey?

Correct Answer is ["A","F"]

Explanation

A mother rushes into the emergency department carrying her toddler who has been exposed to some cleaning products. The child has a chemical smell on their hands, face, and clothes. After ensuring the airway is patent, which action should the nurse take first?

Correct Answer is B

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?