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.
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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Related Questions
Correct Answer is B
Explanation
A. Respiratory acidosis. Respiratory acidosis occurs when there is hypoventilation, leading to an accumulation of carbon dioxide and increased acidity in the blood. Hyperventilation, as described in the scenario, would not lead to respiratory acidosis.
B. Respiratory alkalosis. Hyperventilation leads to respiratory alkalosis by blowing off excessive carbon dioxide, resulting in decreased levels of carbonic acid and increased blood pH.
C. Metabolic acidosis. Metabolic acidosis results from an accumulation of acids or loss of bicarbonate ions. The scenario does not indicate factors leading to metabolic acidosis.
D. Metabolic alkalosis. Metabolic alkalosis occurs due to excessive loss of acids or increased bicarbonate levels, neither of which is suggested in the scenario.
Correct Answer is B
Explanation
A. An increase in breath sounds may suggest improved airflow, but it does not necessarily indicate effective mobilization of secretions.
B. Absence of fine crackles indicates that there are no longer small airway secretions or fluid in the lungs, suggesting that the chest physiotherapy was effective in mobilizing secretions.
C. While the absence of coarse crackles is also a positive finding, fine crackles specifically indicate fluid or secretions in the small airways, making their absence a more direct indicator of the effectiveness of chest physiotherapy.
D. An increase in respiratory rate may indicate respiratory distress or worsening of the condition, rather than effectiveness of the chest physiotherapy in mobilizing secretions.
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