A nurse is caring for a client who has Cushing's syndrome. Which of the following findings should the nurse expect?

Correct Answer: C

Rationale: In clients with Cushing's syndrome, the nurse should expect hyperkalemia. Cushing's syndrome is characterized by excess cortisol levels, which can lead to potassium retention and result in hyperkalemia. Choices A, B, and D are incorrect. Hypotension is not typically associated with Cushing's syndrome; instead, hypertension is more common due to the effects of cortisol. Weight gain, rather than weight loss, is a common symptom of Cushing's syndrome. Hypercalcemia is not a typical finding in Cushing's syndrome; instead, hypocalcemia may occur due to increased urinary calcium excretion.

Correct Answer: A

Rationale: The correct answer is to monitor vital signs. Post-operative patients need close monitoring of their vital signs to detect early signs of complications such as changes in blood pressure, heart rate, temperature, and respiratory rate. While monitoring the surgical site is also important for signs of infection, assessing vital signs takes precedence as it provides immediate information about the patient's overall condition. Checking blood glucose levels may be essential for specific patients but is not the primary assessment for monitoring post-op complications. Checking for abnormal breath sounds is important but falls secondary to monitoring vital signs as it indicates respiratory issues rather than providing a comprehensive assessment of the patient's condition.

Correct Answer: B

Rationale: The correct answer is B: Serotonin syndrome. Serotonin syndrome can occur due to the interaction between citalopram, an SSRI, and St. John's Wort, an herbal supplement. Symptoms of serotonin syndrome include confusion, agitation, rapid heart rate, high blood pressure, dilated pupils, loss of muscle coordination, and sweating. Choices A, C, and D are incorrect as they are not typically associated with the interaction between citalopram and St. John's Wort. Tardive dyskinesia is a movement disorder associated with long-term use of certain medications, pseudoparkinsonism is a side effect of certain antipsychotic medications, and acute dystonia is a movement disorder caused by certain medications like antipsychotics.

Correct Answer: A

Rationale: The appropriate nursing action for a patient experiencing an acute allergic reaction is to administer antihistamines. Antihistamines work by blocking the action of histamine, a chemical released during an allergic reaction, and can help relieve symptoms such as itching, swelling, and hives. Corticosteroids are used for severe allergic reactions not responding to antihistamines, as they have anti-inflammatory properties. Oxygen is administered in cases of respiratory distress, while bronchodilators are used for bronchospasms. However, the first-line intervention for an acute allergic reaction is antihistamines.

Correct Answer: C

Rationale: Applying sequential compression devices is the appropriate intervention for a client at risk for developing deep vein thrombosis (DVT). This intervention helps prevent venous stasis by promoting circulation in the lower extremities, reducing the risk of DVT. Massaging the client's legs every 4 hours is contraindicated as it can dislodge a blood clot and increase the risk of embolism. Administering prophylactic antibiotics is not indicated for preventing DVT. Encouraging the client to remain on bed rest can contribute to venous stasis and increase the risk of developing DVT.

Correct Answer: B

Rationale: Oliguria is a sign of decreased cardiac output. Decreased cardiac output can lead to poor renal perfusion, resulting in decreased urine output (oliguria). This requires immediate intervention to improve cardiac function and perfusion. Shivering (Choice A) is a response to cold stress and does not directly indicate decreased cardiac output. Bradypnea (Choice C) refers to abnormally slow breathing rate and is more indicative of respiratory issues rather than decreased cardiac output. Constricted pupils (Choice D) are associated with the parasympathetic nervous system response and not directly related to cardiac output.

Correct Answer: D

Rationale: The correct answer is D. Calf pain on dorsiflexion following knee surgery may indicate a complication such as deep vein thrombosis, which is a serious condition requiring medical attention. Reporting this finding promptly is crucial to prevent further complications. Choices A, B, and C are within normal range for a client post knee surgery and do not typically indicate immediate complications that require urgent reporting.

Correct Answer: C

Rationale: The correct answer is C. The charge nurse should include information that the proxy can make treatment decisions if the client is under anesthesia. This is a key function of a durable power of attorney for health care. Choices A, B, and D are incorrect because a health care proxy's role is specifically related to making health care decisions, not financial decisions, legal issues, or decisions made under anesthesia.

Correct Answer: B

Rationale: The correct answer is B: PT/INR. When a patient is on warfarin therapy, healthcare providers monitor the PT/INR levels to evaluate the effectiveness of the treatment and assess the risk of bleeding. Monitoring potassium, sodium, or calcium levels is not directly related to warfarin therapy and would not provide the necessary information needed to manage the medication effectively.