The nurse is monitoring a client with Cushing's disease in the postanesthesia care unit (PACU) after a hypophysectomy. Which intervention is most important for the nurse to include in the client's plan of care?

Maintain nasal packing.

Keep head of bed at 30°.

Provide frequent mouth care.

Monitor Intake and output.

Answer and Explanation

The Correct Answer is C

A. Maintaining nasal packing may be important post-hypophysectomy to prevent bleeding or cerebrospinal fluid leaks. However, in the context of Cushing's disease, ensuring oral hygiene is
paramount due to increased risk of infection, especially if the patient is on corticosteroid therapy, which suppresses the immune system.

B. Keeping the head of the bed at 30° helps prevent complications such as cerebral edema and increased intracranial pressure. While this is important post-hypophysectomy, it's not specific to Cushing's disease or a priority over oral care.

C. Providing frequent mouth care is crucial in Cushing's disease due to increased cortisol levels leading to immunosuppression and susceptibility to infections. Additionally, glucocorticoid therapy can cause mucosal dryness and ulceration, necessitating meticulous oral hygiene.

D. Monitoring intake and output is essential postoperatively to assess fluid balance and renal function. While important, it's not the priority in this context compared to oral care, especially considering the risk of dehydration due to increased cortisol levels in Cushing's disease.

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Correct Answer is C

Explanation

A. Digoxin.
Digoxin is a cardiac glycoside that helps increase the force of myocardial contraction and is generally used to treat heart failure. It does not typically pose a significant risk for cardiogenic shock.

B. Hydrochlorothiazide.
Hydrochlorothiazide is a diuretic used to manage fluid retention in heart failure. It can cause electrolyte imbalances but is not directly linked to causing cardiogenic shock.

C. Nadolol.
Nadolol is a beta-blocker, which can reduce the heart rate and the strength of heart contractions. In a client with severe heart failure, excessive beta-blockade can lead to a significant decrease in cardiac output, increasing the risk for cardiogenic shock.

D. Captopril.
Captopril is an ACE inhibitor that helps manage heart failure by reducing afterload and preload.
While it can cause hypotension, it is not typically associated with a direct risk of cardiogenic shock.

A. Promote healing process. B. Decrease abdominal pain. C. Reduce intestinal activity. D. Control diarrhea episodes. E. None F. None

Correct Answer is C

Explanation

Activity restriction does not directly decrease abdominal pain. Pain management in Crohn’s disease is typically achieved through medications, dietary adjustments, and addressing inflammation.

B. While activity restriction may indirectly help decrease abdominal pain by reducing inflammation and promoting healing, it is not the primary purpose of the restriction.
C.The primary goal of activity restriction in Crohn's disease is to reduce intestinal activity. By limiting physical exertion, the intestines are less stimulated, which can help reduce inflammation and give the digestive system a chance to rest and recover.
D. While activity restriction may help control diarrhea episodes by reducing physical stress on the intestines, the primary purpose is to promote healing and reduce inflammation. Control of diarrhea may be achieved through other interventions such as dietary modifications and
medication management.

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The nurse is monitoring a client with Cushing's disease in the postanesthesia care unit (PACU) after a hypophysectomy. Which intervention is most important for the nurse to include in the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with heart failure. Which of these prescribed medications places the client at risk for cardiogenic shock?

Correct Answer is C

Explanation

Restricted activity is prescribed for a client with Crohn's disease. The nurse should explain that the primary purpose of the activity restriction is to obtain which outcome?

Correct Answer is C

Explanation

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