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The nurse providing care for a patient with Cushing syndrome has identified the nursing diagnosis of risk for injury related to weakness. How should the nurse best reduce this risk?
- A. Establish falls prevention measures
- B. Encourage bed rest whenever possible
- C. Encourage the use of assistive devices
- D. Provide constant supervision
Correct Answer: A
Rationale: The nurse should take action to prevent the patients risk for falls. Bed rest carries too many harmful effects, however, and assistive devices may or may not be necessary. Constant supervision is not normally required or practicable.
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A patient has been admitted to the critical care unit with a diagnosis of thyroid storm. What interventions should the nurse include in this patients immediate care? Select all that apply.
- A. Administering diuretics to prevent fluid overload
- B. Administering beta blockers to reduce heart rate
- C. Administering insulin to reduce blood glucose levels
- D. Applying interventions to reduce the patients temperature
- E. Administering corticosteroids
Correct Answer: B,D
Rationale: Thyroid storm necessitates interventions to reduce heart rate and temperature. Diuretics, insulin, and steroids are not indicated to address the manifestations of this health problem.
A patient with Cushing syndrome as a result of a pituitary tumor has been admitted for a transsphenoidal hypophysectomy. What would be most important for the nurse to monitor before, during, and after surgery?
- A. Blood glucose
- B. Assessment of urine for blood
- C. Weight
- D. Oral temperature
Correct Answer: A
Rationale: Before, during, and after this surgery, blood glucose monitoring and assessment of stools for blood are carried out. The patients blood sugar is more likely to be volatile than body weight or temperature. Hematuria is not a common complication.
The nurse is caring for a patient with Addisons disease who is scheduled for discharge. When teaching the patient about hormone replacement therapy, the nurse should address what topic?
- A. The possibility of precipitous weight gain
- B. The need for lifelong steroid replacement
- C. The need to match the daily steroid dose to immediate symptoms
- D. The importance of monitoring liver function
Correct Answer: B
Rationale: Because of the need for lifelong replacement of adrenal cortex hormones to prevent addisonian crises, the patient and family members receive explicit education about the rationale for replacement therapy and proper dosage. Doses are not adjusted on a short-term basis. Weight gain and hepatotoxicity are not common adverse effects.
A patient has been assessed for aldosteronism and has recently begun treatment. What are priority areas for assessment that the nurse should frequently address? Select all that apply.
- A. Pupillary response
- B. Creatinine and BUN levels
- C. Potassium level
- D. Peripheral pulses
- E. BP
Correct Answer: C,E
Rationale: Patients with aldosteronism exhibit a profound decline in the serum levels of potassium, and hypertension is the most prominent and almost universal sign of aldosteronism. Pupillary response, peripheral pulses, and renal function are not directly affected.
A patient with Cushing syndrome has been hospitalized after a fall. The dietician consulted works with the patient to improve the patients nutritional intake. What foods should a patient with Cushing syndrome eat to optimize health? Select all that apply.
- A. Foods high in vitamin D
- B. Foods high in calories
- C. Foods high in protein
- D. Foods high in calcium
- E. Foods high in sodium
Correct Answer: A,C,D
Rationale: Foods high in vitamin D, protein, and calcium are recommended to minimize muscle wasting and osteoporosis. Referral to a dietitian may assist the patient in selecting appropriate foods that are also low in sodium and calories.