Which nursing action would be appropriate to implement when a client has a diagnosis of pheochromocytoma?

Which nursing action would be appropriate to implement when a client has a diagnosis of pheochromocytoma?

• A. Weigh the client.
• B. Test the client's urine for glucose.
• C. Monitor the client's blood pressure.
• D. Palpate the client's skin to determine warmth.

Answer: (C)

Pheochromocytoma causes excessive catecholamine release, which leads to sudden and severe blood pressure spikes. The primary nursing action is to monitor blood pressure continuously or at frequent intervals to detect hypertensive crises early, guide antihypertensive therapy, and assess how well treatment is controlling the BP. This monitoring is essential for safety and for managing preoperative preparation and potential intraoperative risks. Avoid abdominal palpation or vigorous manipulation of the abdomen, because physical stimulation can provoke further catecholamine release and precipitate a dangerous BP surge. Weighing the client, testing urine for glucose, or palpating the skin for warmth do not address the critical risk of BP instability. Therefore, monitoring the client’s blood pressure is the most appropriate nursing action.

Pheochromocytoma causes excessive catecholamine release, which leads to sudden and severe blood pressure spikes. The primary nursing action is to monitor blood pressure continuously or at frequent intervals to detect hypertensive crises early, guide antihypertensive therapy, and assess how well treatment is controlling the BP. This monitoring is essential for safety and for managing preoperative preparation and potential intraoperative risks.

Avoid abdominal palpation or vigorous manipulation of the abdomen, because physical stimulation can provoke further catecholamine release and precipitate a dangerous BP surge. Weighing the client, testing urine for glucose, or palpating the skin for warmth do not address the critical risk of BP instability. Therefore, monitoring the client’s blood pressure is the most appropriate nursing action.