Patho Patho #43

Question

The nurse places priority on which assessment for a client with a pheochromocytoma:

Answers

  1. 1. Blood pressure.
    • Rationale:

      This answer is correct because the nurse should place high priority on monitoring blood pressure in clients with pheochromocytoma due to the risk for dangerous hypertension.

  2. 2. Axillary temperature.
    • Rationale:

      This answer choice is not correct because, although monitoring temperature is important for all clients, blood pressure is the highest priority for clients with pheochromocytoma.

  3. 3. Pain rating.
    • Rationale:

      This answer choice is not correct because, although clients with pheochromocytoma will report headaches, the most important assessment data is blood pressure due to dangerous hypertension.

  4. 4. Capillary refill time.
    • Rationale:

      This answer choice is not correct because, although capillary refill time is part of the comprehensive physician assessment for all clients, blood pressure is the most critical assessment data for clients with pheochromocytoma.

Overview

The focus of this question is asking the nurse to identify which data is most critical when performing an assessment on a client with a diagnosis of pheochromocytoma. Pheochromocytoma is a tumor on the adrenal medulla which produces ectopic epinephrine and norepinephrine. As a result, clients experience dangerous hypertension, diaphoresis, and headaches. Therefore, the most important assessment data for the nurse to obtain for this client is blood pressure.

Explanation

Learning Outcomes

A pheochromocytoma is a tumor that causes the adrenal medulla to produce excessive amounts of catecholamines. Catecholamines, or fight or flight hormones, increase the body’s stress response by causing massive vasoconstriction resulting in dangerously high blood pressure in clients with pheochromocytoma. Frequent blood pressure measurements are therefore the most critical assessments for the nurse to perform for clients with a diagnosis of pheochromocytoma.

Test Taking Tip

A-B-C; dangerous hypertension is a serious threat to circulation making blood pressure the most critical assessment for clients with pheochromocytoma.

Video Rationale