A patient suspected of having Pheochromocytoma complaining of palpitation, sweating and headache. Which asses… - WCL Staff Nurse - 2019

WCL Staff Nurse - 2019

Medical & Surgical Nursing

Hard

Appeared in: WCL Staff Nurse - 2019

Explanation

Pheochromocytoma is a tumor of the adrenal medulla that secretes excessive amounts of catecholamines (epinephrine and norepinephrine).
This hormonal surge leads to the classic triad of symptoms: palpitations, headache, and profuse sweating (diaphoresis).
The most dangerous consequence of this catecholamine release is severe hypertension, which can be paroxysmal or sustained.
Assessing blood pressure is the most critical and essential action to monitor for a hypertensive crisis and prevent life-threatening complications like stroke, myocardial infarction, or dissecting aneurysm.

Option A: This assesses neurological function related to the brainstem and cranial nerves, which is not a primary or direct indicator of a pheochromocytoma crisis. While severe hypertension can cause neurological changes, pupillary reaction is not the initial priority assessment.
Option B: This is not a standard or recognized medical assessment term. It does not provide any clinically relevant data for this condition.
Option D: Catecholamine excess can cause hyperglycemia by stimulating glycogenolysis. While monitoring blood glucose is important, it is not the most essential initial assessment. The immediate life-threatening risk is from severe hypertension, not high blood sugar.

Clinical Relevance

Nursing practice connection: Use the key finding related to Priority nursing assessment for a patient with suspected pheochromocytoma to guide bedside assessment, documentation, and the next nursing action.
A nurse's priority in caring for a patient with suspected pheochromocytoma is the prompt recognition and management of a hypertensive crisis. This involves frequent and accurate BP monitoring.
A critical patient safety measure is to avoid palpating the abdomen, as this can manipulate the tumor and trigger a massive release of catecholamines, precipitating a severe hypertensive crisis.
What if? If the patient's blood pressure was 210/120 mmHg, the nurse's immediate action would be to administer a rapid-acting alpha-blocker (like phentolamine) as prescribed, place the patient in a high-Fowler's position, and notify the physician immediately, as this is a medical emergency.

How to Approach the Question

First, identify the key terms in the question: 'Pheochromocytoma,' 'palpitation,' 'sweating,' and 'headache.'
Recognize that these three symptoms form the classic triad for pheochromocytoma.
Recall the pathophysiology of this condition: a tumor of the adrenal medulla releases excess catecholamines.
Connect the pathophysiology to the most immediate life-threatening risk. The surge of catecholamines causes severe hypertension.
Evaluate the options based on this priority. Assessing blood pressure directly measures this critical parameter.
Eliminate the other options: Pupillary reaction is a secondary assessment, 'hand gap' is not a valid term, and blood glucose is a less immediate priority than blood pressure.

Concept Tested & Keywords

Concept Tested: Priority nursing assessment for a patient with suspected pheochromocytoma.
Stem keywords: Pheochromocytoma, palpitation, sweating, headache, essential assessment
Lead-in keywords: essential
Clinical cues: The combination of palpitations, sweating, and headache is the classic triad for pheochromocytoma, strongly suggesting a hypertensive crisis.

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E6 Nursing Brunner Adult Health 3SA Vol 1 Part 4 p. 33-35

E6 Medicine Harrison 22e Part 2 p. 978-980