Nokea
The nurse is caring for a patient with Cushing's syndrome who returns to the surgical unit following an adrenalectomy. Which of the following actions during the initial postoperative period has the highest priority?
- A. Monitoring for infection
- B. Protecting the patient's skin
- C. Maintaining fluid and electrolyte status
- D. Preventing severe emotional disturbances
Correct Answer: C
Rationale: After adrenalectomy, the patient is at risk for circulatory instability caused by fluctuating hormone levels, and the focus of care is to assess and maintain fluid and electrolyte status through the use of IV fluids and corticosteroids. The other goals are also important for the patient but are not as immediately life-threatening as the circulatory collapse that can occur with fluid and electrolyte disturbances.
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Which of the following actions should the nurse take first when caring for a patient who has just arrived on the unit after a thyroidectomy?
- A. Check the dressing for bleeding.
- B. Assess respiratory rate and effort.
- C. Take the blood pressure and pulse.
- D. Support the patient's head with pillows.
Correct Answer: B
Rationale: Airway obstruction is a possible complication after thyroidectomy because of swelling or bleeding at the site or tetany, and the priority nursing action is to assess the airway. The other actions are also part of the standard nursing care post-thyroidectomy but are not as high in priority.
The nurse is providing preoperative teaching for a patient scheduled for a hypophysectomy for treatment of a pituitary adenoma. Which of the following instructions should the nurse include in patient teaching?
- A. Cough and deep breathe every 2 hours postoperatively
- B. Bed rest for the first 24 hours after the surgery
- C. Be positioned flat with sandbags at the head postoperatively
- D. Have a NG tube after the surgery
Correct Answer: D
Rationale: The patient should be taught that they will have a NG tube after surgery. It is not necessary to remain on bed rest after this surgery. Coughing is discouraged because it may cause leakage of cerebrospinal fluid (CSF) from the suture line. The head of the bed should be elevated 30 degrees to reduce pressure on the sella turcica and decrease the risk for headaches.
The nurse is caring for a patient with Graves' disease who has to,2026. 11:3.29. following actionspl. All is included in the plan of care?
- A. Apply eye patches to protect the cornea from irritation.
- B. Place cold packs on the eyes to
- C. Elevate the head of the patient's bed to reduce periorbital
- D. Teach the patient to blink every few seconds to lubric
Correct Answer: C
Rationale: The patient should sit upright as much as possible to promote fluid drainage from the periorbital area. With exophthalmos, the patient is unable to close the eyes completely. Lubrication of the eyes, rather than eye patches, will protect the eyes from developing corneal scarring. The swelling of the eye is not caused by excessive blood flow to the eye, so cold packs will not be helpful.
The nurse is caring for a patient with a diagnosis of Cushing's syndrome. Which of the following data should the nurse anticipate finding during the admission assessment?
- A. Persistently low blood pressure
- B. Bronzed appearance of the skin
- C. Decreased axillary and pubic hair
- D. Purplish red streaks on the abdomen
Correct Answer: D
Rationale: Purplish-red striae on the abdomen are a common clinical manifestation of Cushing's syndrome. Hypotension and bronzed-appearing skin are manifestations of Addison's disease. Decreased axillary and pubic hair occur with androgen deficiency.
The nurse is caring for a patient with hypertension who is diagnosed with a pheochromocytoma. Which of the following findings should the nurse monitor in the patient?
- A. Flushing
- B. Headache
- C. Bradycardia
- D. Hypoglycemia
Correct Answer: B
Rationale: The classic clinical manifestations of pheochromocytoma are hypertension, tachycardia, severe pounding headache, diaphoresis, and abdominal or chest pain. Elevated blood glucose may also occur because of sympathetic nervous system stimulation. Bradycardia and flushing would not be expected.