The nurse is assessing a client with possible Cushing’s syndrome. In a client with Cushing’s syndrome, the nurse would expect to find:
- A. hypotension
- B. thick, coarse skin
- C. deposits of adipose tissue in the trunk and dorsocervical area
- D. weight gain in arms and legs
Correct Answer: C
Rationale: The correct answer is C: deposits of adipose tissue in the trunk and dorsocervical area. In Cushing's syndrome, there is excess cortisol production leading to central obesity with fat accumulation in the trunk and dorsocervical area (buffalo hump). This is due to cortisol's role in redistributing fat.
A: hypotension is incorrect because individuals with Cushing's syndrome typically have hypertension due to the effects of excess cortisol on blood pressure regulation.
B: thick, coarse skin is incorrect as individuals with Cushing's syndrome may have thin, fragile skin due to decreased collagen formation.
D: weight gain in arms and legs is incorrect as the weight gain in Cushing's syndrome tends to be centralized in the trunk and face rather than the extremities.
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A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
- A. Begin with introductions.
- B. Ask about the chief concerns or problems.
- C. Explain that the interview will be over in a few minutes.
- D. Tell the patient “I will be back to administer medications in 1 hour.”
Correct Answer:
Rationale: Correct Answer: B: Ask about the chief concerns or problems.
Rationale: After setting the agenda, the nurse should proceed by asking about the patient's chief concerns or problems to focus the interview on the patient's needs. This step helps in gathering important information and establishing rapport. Introductions are usually done at the beginning of the interview, so it is not the next step. Explaining that the interview will be over in a few minutes can create anxiety and hinder open communication. Telling the patient about administering medications in 1 hour is not relevant at this point in the interview.
The nurse is aware that multiple sclerosis is a progressive disease of the central nervous system characterized by:
- A. Axon degeneration
- B. Sclerosed patches of nervous system
- C. Demyelination of the brain and spinal cord
- D. All of the above
Correct Answer: D
Rationale: Step 1: Multiple sclerosis (MS) is a progressive disease affecting the central nervous system.
Step 2: Axon degeneration occurs in MS, leading to impaired nerve signal transmission.
Step 3: MS is characterized by sclerosed patches, or plaques, in the nervous system.
Step 4: Demyelination of the brain and spinal cord is a hallmark feature of MS.
Step 5: Therefore, all of the above choices are correct as they accurately describe key features of MS.
Which of the ff finding would confirm that a female client has mastitis? Choose all that apply
- A. A crack in the nipple or the areola
- B. Multiple lumps within the breast tissue
- C. Swollen, firm, and hard breasts
- D. Enlargement of the axillary lymph nodes
Correct Answer: C
Rationale: The correct answer is C because mastitis typically presents with swollen, firm, and hard breasts due to inflammation and infection of the breast tissue. This occurs as a result of milk stasis and bacterial infection. Option A is incorrect because a crack in the nipple or areola can be indicative of nipple trauma or infection, not necessarily mastitis. Option B is incorrect because multiple lumps within the breast tissue may suggest fibrocystic changes or breast cancer, but not specifically mastitis. Option D is incorrect because enlargement of the axillary lymph nodes is more commonly seen in breast cancer, not mastitis.
A young male client visits a nurse with a complaint of chronic tension headaches. Which of the ff is the most appropriate nursing instruction to manage the client?
- A. Instructing the client to monitor for signs of bruising or bleeding
- B. Suggesting eating and swallowing techniques that reduce the potential for aspiration
- C. Counselling on alternate therapies
- D. Advising the client to change sleeping positions frequently
Correct Answer: C
Rationale: The correct answer is C: Counselling on alternate therapies. Chronic tension headaches may be exacerbated by stress or other psychological factors, making counseling an appropriate intervention. The nurse can explore relaxation techniques, stress management strategies, or cognitive-behavioral therapy to help the client manage their headaches.
A: Instructing the client to monitor for signs of bruising or bleeding is unrelated to tension headaches and not a priority in this situation.
B: Suggesting eating and swallowing techniques that reduce the potential for aspiration is not relevant to tension headaches and is not the most appropriate intervention.
D: Advising the client to change sleeping positions frequently may help with other types of headaches but is not the most effective strategy for managing chronic tension headaches.
The nurse is developing a plan of care for marrow suppression, the major dose-limiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow suppression become noticeable?
- A. 24 hours
- B. 7 to 14 days
- C. 2 to 4 days
- D. 21 to 28 days
Correct Answer: B
Rationale: The correct answer is B: 7 to 14 days. Marrow suppression from floxuridine typically occurs 1-2 weeks after administration due to its effects on rapidly dividing cells in the bone marrow. This is known as the nadir period. Choices A, C, and D are incorrect because 24 hours is too soon for noticeable effects, 2 to 4 days is too short for the nadir period, and 21 to 28 days is too long for the onset of marrow suppression. The correct choice aligns with the expected timeframe for floxuridine's impact on bone marrow function.