Nokea
You are developing a care plan for a patient with Cushing syndrome. What nursing diagnosis would have the highest priority in this care plan?
- A. Risk for injury related to weakness
- B. Ineffective breathing pattern related to muscle weakness
- C. Risk for loneliness related to disturbed body image
- D. Autonomous dysreflexia related to neurologic changes
Correct Answer: A
Rationale: The nursing priority is to decrease the risk of injury by establishing a protective environment. The patient who is weak may require assistance from the nurse in ambulating to prevent falls or bumping corners or furniture. The patients breathing will not be affected and autonomic dysreflexia is not a plausible risk. Loneliness may or may not be an issue for the patient, but safety is a priority.
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The physician has ordered a fluid deprivation test for a patient suspected of having diabetes insipidus. During the test, the nurse should prioritize what assessments?
- A. Temperature and oxygen saturation
- B. Heart rate and BP
- C. Breath sounds and bowel sounds
- D. Color, warmth, movement, and sensation of extremities
Correct Answer: B
Rationale: The fluid deprivation test is carried out by withholding fluids for 8 to 12 hours or until 3% to 5% of the body weight is lost. The patients condition needs to be monitored frequently during the test, and the test is terminated if tachycardia, excessive weight loss, or hypotension develops. Consequently, BP and heart rate monitoring are priorities over the other listed assessments.
A patient who has been taking corticosteroids for several months has been experiencing muscle wasting. The patient has asked the nurse for suggestions to address this adverse effect. What should the nurse recommend?
- A. Activity limitation to conserve energy
- B. Consumption of a high-protein diet
- C. Use of OTC vitamin D and calcium supplements
- D. Passive range-of-motion exercises
Correct Answer: B
Rationale: Muscle wasting can be partly addressed through increased protein intake. Passive ROM exercises maintain flexibility, but do not build muscle mass. Vitamin D and calcium supplements do not decrease muscle wasting. Activity limitation would exacerbate the problem.
While assisting with the surgical removal of an adrenal tumor, the OR nurse is aware that the patients vital signs may change upon manipulation of the tumor. What vital sign changes would the nurse expect to see?
- A. Hyperthermia and tachypnea
- B. Hypertension and heart rate changes
- C. Hypotension and hypothermia
- D. Hyperthermia and bradycardia
Correct Answer: B
Rationale: Manipulation of the tumor during surgical excision may cause release of stored epinephrine and norepinephrine, with marked increases in BP and changes in heart rate. The use of sodium nitroprusside and alpha-adrenergic blocking agents may be required during and after surgery. While other vital sign changes may occur related to surgical complications, the most common changes are related to hypertension and changes in the heart rate.
The home care nurse is conducting patient teaching with a patient on corticosteroid therapy. To achieve consistency with the bodys natural secretion of cortisol, when would the home care nurse instruct the patient to take his or her corticosteroids?
- A. In the evening between 4 PM and 6 PM
- B. Prior to going to sleep at night
- C. At noon every day
- D. In the morning between 7 AM and 8 AM
Correct Answer: D
Rationale: In keeping with the natural secretion of cortisol, the best time of day for the total corticosteroid dose is in the morning from 7 to 8 AM. Large-dose therapy at 8 AM, when the adrenal gland is most active, produces maximal suppression of the gland. Also, a large 8 AM dose is more physiologic because it allows the body to escape effects of the steroids from 4 PM to 6 AM, when serum levels are normally low, thus minimizing cushingoid effects.
Following an addisonian crisis, a patients adrenal function has been gradually regained. The nurse should ensure that the patient knows about the need for supplementary glucocorticoid therapy in which of the following circumstances?
- A. Episodes of high psychosocial stress
- B. Periods of dehydration
- C. Episodes of physical exertion
- D. Administration of a vaccine
Correct Answer: A
Rationale: During stressful procedures or significant illnesses, additional supplementary therapy with glucocorticoids is required to prevent addisonian crisis. Physical activity, dehydration and vaccine administration would not normally be sufficiently demanding such to require glucocorticoids.