Which admission assessment findings should the nurse document related to a client who has been diagnosed with Cushing’s syndrome?

Choice A reason: Reorienting to day and time frequently is a nursing intervention that the nurse should implement, because it can help the client to reduce confusion, anxiety, and disorientation, which may contribute to the auditory hallucinations. The nurse should use simple and clear language, speak slowly and calmly, and provide cues and reminders, such as a clock, a calendar, or a picture, to help the client to orient to reality.

Choice B reason: Applying soft wrist restraints bilaterally is not a nursing intervention that the nurse should implement, unless it is absolutely necessary and ordered by the doctor. Restraints can increase the client's agitation, anxiety, and fear, and they can also cause physical and psychological harm, such as skin breakdown, nerve damage, or loss of dignity. The nurse should use restraints only as a last resort, after trying other less restrictive alternatives, such as verbal de-escalation, distraction, or medication.

Choice C reason: Administering a PRN dose of lorazepam is a nursing intervention that the nurse should implement, if it is prescribed by the doctor and indicated by the client's condition. Lorazepam is a benzodiazepine that can help the client to relax, reduce anxiety, and sedate the central nervous system, which may alleviate the auditory hallucinations. The nurse should monitor the client's vital signs, level of consciousness, and respiratory status, and report any adverse effects, such as hypotension, bradycardia, or respiratory depression.

Choice D reason: Turning the television on for distraction is not a nursing intervention that the nurse should implement, because it can worsen the client's auditory hallucinations, confusion, and agitation. The television can provide too much stimulation, noise, and information, which can overload the client's sensory perception and interfere with their ability to distinguish reality from hallucination. The nurse should provide a quiet and calm environment, and limit the sources of auditory input.

Choice E reason: Presenting a calm, supportive demeanor is a nursing intervention that the nurse should implement, because it can help the client to feel safe, comfortable, and respected, and to establish a trusting relationship with the nurse. The nurse should show empathy, compassion, and patience, and avoid arguing, criticizing, or dismissing the client's hallucinations. The nurse should acknowledge the client's feelings, validate their distress, and reassure them that they are not alone.

Choice A reason: Inserting a nasogastric tube (NGT) and attaching to low intermittent suction is the priority intervention for a client with peptic ulcer disease who is vomiting and experiencing epigastric pain and nausea. This can help decompress the stomach, remove gastric contents, prevent further bleeding, and relieve the symptoms. The NGT should be inserted carefully and checked for proper placement before suctioning.

Choice B reason: Giving a prescribed analgesic for temperature above 101°F (38.3° C) is not the first intervention for a client with peptic ulcer disease who is vomiting and experiencing epigastric pain and nausea. Temperature elevation can indicate infection or inflammation, which can be treated with antibiotics or anti-inflammatory drugs. However, analgesics can have adverse effects on the gastrointestinal tract, such as irritation, ulceration, or bleeding. Analgesics should be given cautiously and after the cause of the fever is identified.

Choice C reason: Placing an indwelling urinary catheter and attaching a bedside drainage unit is not the first intervention for a client with peptic ulcer disease who is vomiting and experiencing epigastric pain and nausea. Urinary catheterization can help monitor the fluid balance, renal function, and blood loss of the client, but it is not a priority in this situation. Urinary catheterization can also pose risks of infection, trauma, or obstruction, and should be avoided unless necessary.

Choice D reason: Sending the client to x-ray for a flat plate of the abdomen is not the first intervention for a client with peptic ulcer disease who is vomiting and experiencing epigastric pain and nausea. X-ray can help diagnose the location and extent of the ulcer, perforation, or obstruction, but it is not a priority in this situation. X-ray can also expose the client to radiation, which can be harmful, and should be done only after the client is stabilized.