The nurse is managing the care of a client with Cushing's syndrome. Which intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Weigh the client and report any weight gain.

Reporting any client complaints of pain or discomfort.

Evaluate the client for sleep disturbances.

Note and report the client's food and liquid intake during meals and snacks.

Assess the client for weakness and fatigue.

Answer and Explanation

Correct Answer : A,B,D

A)   Correct- Weighing the client and reporting any weight gain is a routine measurement that can be safely performed by the UAP. Weight gain can be an important indicator of fluid retention, a common issue in Cushing's syndrome.
B)   Correct- Reporting any client complaints of pain or discomfort is important for monitoring the client's well-being and promptly addressing any potential issues.
C)   Incorrect- Evaluating the client for sleep disturbances involves assessing the client's sleep patterns, quality, and potential disruptions. This requires nursing judgment and a deeper understanding of the client's condition and potential contributing factors, so it's not appropriate to delegate this task to the UAP.
D)   Correct- Noting and reporting the client's food and liquid intake during meals and snacks is part of monitoring the client's nutritional status, which is an appropriate task for the UAP.
E)   Incorrect- Assessing the client for weakness and fatigue involves a more comprehensive evaluation of the client's physical and physiological status, which requires nursing expertise. The nurse should directly assess and interpret these symptoms in the context of Cushing's syndrome to provide appropriate interventions.

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Correct Answer is D

Explanation

A) This can be done if initial non-pharmacological interventions do not relieve symptoms, but it is not the first step.
B) Monitoring blood pressure is important, but it is secondary to removing the stimulus causing the dysreflexia.
C) Incorrect- While education is important for long-term management, the client is currently experiencing symptoms that need immediate attention. The priority is to assess and address the current symptoms.
D) The client is likely experiencing autonomic dysreflexia, characterized by a sudden and severe increase in blood pressure, flushing, headache, and other symptoms triggered by a noxious stimulus below the level of injury. The first step in managing autonomic dysreflexia is to identify and eliminate the triggering stimulus. For clients with a Foley catheter, a common cause of autonomic dysreflexia is bladder distention due to a kinked or obstructed catheter. Relieving any kinks or obstructions in the Foley tubing can immediately alleviate the symptoms.

A. Remain non-judgmental and assure the client of confidentiality. B. Provide counseling that most contraceptives protect against infection. C. Clarify that all STIs are transmitted through sexual intercourse. D. Inform the client that complications will not result from reinfection.

Correct Answer is A

Explanation

It is essential for the nurse to maintain a non-judgmental and supportive attitude when caring for clients with STIs, including genital herpes. Assuring the client of confidentiality helps to create a safe and trusting environment, encouraging open communication about the client's concerns and experiences.

This approach promotes the client's well-being and allows for effective education and support regarding STI prevention, transmission, and management.

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The nurse is managing the care of a client with Cushing's syndrome. Which intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

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