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) Autonomic dysreflexia related to neurologic changes
Ans: A
Feedback:
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 patient's 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.
You might also like to view...
Malnutrition can be too much or too little nutrition. What can malnutrition do in the human body?
A) Decrease risk of disease complications B) Decrease wound healing time C) Contribute to shorter hospital stays D) Prolong confinement to bed
The nurse is caring for a child with acute glomerulonephritis. Which manifestations would the nurse most likely assess in this child?
A) Loose, dark stools B) Smoky-colored urine C) Strawberry red tongue D) Jaundiced skin
Children can distinguish between fantasy and reality by what age?
1. 3 years of age 2. 1 year of age 3. 7 years of age 4. 5 years of age
Raymond, a patient with Zollinger-Ellison (ZE) syndrome, is administered a dose of 6 mg of cimetidine. How long will it take for peak absorption to occur?
A. 10 minutes B. Within 90 minutes C. 6 hours D. 2 to 3 hours