A nurse cares for a client with chronic hypercortisolism. Which ...

[Alainaaa8]

A nurse cares for a client with chronic hypercortisolism. Which action should the nurse take?
 
  a. Wash hands when entering the room.
  b. Keep the client in airborne isolation.
  c. Observe the client for signs of infection.
  d. Assess the client's daily chest x-ray.

Question 2

A nurse cares for a client who is recovering from a hypophysectomy. Which action should the nurse take first?
 
  a. Keep the head of the bed flat and the client supine.
  b. Instruct the client to cough, turn, and deep breathe.
  c. Report clear or light yellow drainage from the nose.
  d. Apply petroleum jelly to lips to avoid dryness.

[wilsonbho]

Answer to Question 1

ANS: A
Excess cortisol reduces the number of circulating lymphocytes, inhibits maturation of macrophages, reduces antibody synthesis, and inhibits production of cytokines and inflammatory chemicals. As a result, these clients are at greater risk of infection and may not have the expected inflammatory manifestations when an infection is present. The nurse needs to take precautions to decrease the client's risk. It is not necessary to keep the client in isolation. The client does not need a daily chest x-ray.

Answer to Question 2

ANS: C
A light yellow drainage or a halo effect on the dressing is indicative of a cerebrospinal fluid leak. The client should have the head of the bed elevated after surgery. Although deep breathing is important postoperatively, coughing should be avoided to prevent cerebrospinal fluid leakage. Although application of petroleum jelly to the lips will help with dryness, this instruction is not as important as reporting the yellowish drainage.