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Which nursing interventions are most appropriate for nursing in the health of a client with Cushing's syndrome? Select all that apply.
- A. Have the client sleep on a convoluted (egg-crate) foam mattress.
- B. Ambulate the client at frequent intervals.
- C. Advise the client to ask for assistance when getting up.
- D. Offer high-carbohydrate nourishment.
- E. Check the client frequently for suicidal ideation.
- F. Instruct the client to wear loose-fitting clothing.
Correct Answer: A,C,E,F
Rationale: These interventions address skin breakdown, fall risk, mood changes, and comfort in Cushing's syndrome.
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Which assessment findings would the nurse expect to document the patient's health care, and the patient's health care? Select all that apply.
- A. The client is hypertensive and tachycardic.
- B. The client is dyspneic and hypotensive.
- C. The client breathes noisily and smells of acetone.
- D. The client stares blankly and smells of alcohol.
- E. The client has warm, flushed skin and has vomited.
- F. The client complains of abdominal pain and is thirsty.
Correct Answer: C,E,F
Rationale: DKA is characterized by acetone breath, warm/flushed skin, vomiting, abdominal pain, and thirst due to hyperglycemia and dehydration.
When directing the nursing assistant to weigh the client, which instruction is most important for obtaining accurate data?
- A. Have the client stand on a bedside scale.
- B. Weigh the client at the same time each day.
- C. Ask that slippers be removed when being weighed.
- D. Ask about the client's pre-disease weight.
Correct Answer: B
Rationale: Weighing the client at the same time each day ensures consistency and accounts for daily fluctuations in weight due to meals, hydration, or other factors.
In response to a question about timing of symptoms during the nursing history, when is the client most likely to describe that symptoms typically occur?
- A. After fasting more than 6 hours
- B. About 2 hours after eating a meal
- C. Late in the evening, before bedtime
- D. Early in the morning, before breakfast
Correct Answer: A
Rationale: Hyperinsulinism causes hypoglycemia, which is more likely after fasting due to excess insulin lowering blood glucose.
The client with an acute exacerbation of chronic pancreatitis has a nasogastric (N/G) tube. Which interventions should the nurse implement? Select all that apply.
- A. Monitor the client's bowel sounds.
- B. Monitor the client's food intake.
- C. Assess the client's intravenous site.
- D. Provide oral and nasal care.
- E. Monitor the client's blood glucose.
Correct Answer: A,C,D,E
Rationale: Monitoring bowel sounds, IV site, oral/nasal care, and glucose manage NG tube complications and pancreatitis-related risks (e.g., hyperglycemia). Food intake is irrelevant with NPO status.
Twelve hours after a transsphenoidal hypophysectomy, the client keeps clearing his throat and complains of a drip in his mouth. To accurately assess this, the nurse should test the fluid for:
- A. sugar.
- B. protein.
- C. bacteria.
- D. blood.
Correct Answer: A
Rationale: A post-nasal drip post-transsphenoidal hypophysectomy may indicate cerebrospinal fluid (CSF) leakage, which contains glucose (sugar), unlike saliva or mucus.