Nokea
A client is being admitted with syndrome of inappropriate diuretic hormone. Which does the nurse expect to observe?
- A. Increased thirst
- B. Tachycardia
- C. Polyuria
- D. Hostility
- E. Muscle weakness
Correct Answer: B,D,E
Rationale: SIADH causes water retention, leading to hyponatremia, which can cause tachycardia (B), hostility (D), and muscle weakness (E). Increased thirst (A) and polyuria (C) are more associated with diabetes insipidus.
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A client has been admitted to the nursing unit with the diagnosis of severe anemia. She is slightly short of breath, has episodes of dizziness, and complains her heart sometimes feels like it will 'beat out of her chest.' The physician has ordered her to receive 2 U of packed red blood cells. The most important nursing action to be taken is:
- A. Starting an 18-gauge IV infusion
- B. Having the consent form on the chart
- C. Administering the correct blood product to the correct client
- D. Transfusing the blood in a 2-hour time frame
Correct Answer: C
Rationale: An 18-gauge IV is an appropriate size for administering blood; however, client safety demands that the right blood product must be administered. The consent form is legally necessary to be on the chart, but client safety is maintained by giving the correct blood component to the correct client. Administering the correct blood product to the correct client will maintain physiological safety and minimize transfusion reactions. The blood administration should take place over the ordered time frame designated by the physician.
Which nursing intervention would be of highest priority when caring for a patient admitted in sickle cell vaso-occlusive crisis?
- A. Starting intravenous normal saline
- B. Applying oxygen
- C. Applying heat to the affected joints
- D. Administering pain medication
Correct Answer: D
Rationale: In sickle cell vaso-occlusive crisis severe pain results from blocked blood vessels. Administering pain medication is the highest priority to relieve acute discomfort and improve patient comfort. While IV fluids and oxygen are important pain management is the most urgent need.
The mother of a child with chickenpox wants to know if there is a medication that will shorten the course of the illness. Which medication is sometimes used to speed healing of the lesions and shorten the duration of fever and itching?
- A. Zovirax (acyclovir)
- B. Varivax (varicella vaccine)
- C. VZIG (varicella-zoster immune globulin)
- D. Periactin (cyproheptadine)
Correct Answer: A
Rationale: Acyclovir (Zovirax) is an antiviral that can reduce the severity and duration of chickenpox symptoms, including lesions, fever, and itching.
A male client is admitted to the psychiatric unit after experiencing severe depression. He states that he intends to kill himself, but he asks the nurse not to repeat his intentions to other staff members. Which response demonstrates understanding and appropriate action on the part of the nurse?
- A. I understand you're depressed, but killing yourself is not a reasonable option.'
- B. We need to discuss this further, but right now let's complete these forms.'
- C. Don't do that, you have so much to live for. You have a wonderful wife and children. The client in the next room has no one.'
- D. This is very serious. I do not want any harm to come to you. I will have to report this to the rest of the staff.'
Correct Answer: D
Rationale: To the client, suicide may be a reasonable action and the only one he can cope with at this time. This response indicates to the client that his intention to commit suicide is not important to the nurse at this time. The client is so depressed that he is not able to see the positive aspects of his life. At no time should the nurse discuss another client's problems in conversation. This statement tells the client that the nurse recognizes his problem is of a serious nature and will take all steps necessary to help him.
A 42-year-old client presents with a diagnosis of paranoid schizophrenia. She has become increasingly restless and verbally argumentative, and her speech has become pressured. She is exhibiting signs of:
- A. Depression
- B. Agitation
- C. Psychotic ideation
- D. Anhedonia
Correct Answer: B
Rationale: Signs of depression would include withdrawal, sadness, morbid thoughts, insomnia, early awakening, etc. These clinical features are classic signs of agitation. Psychotic ideation includes delusional thoughts, bizarre behavior, disorganized thinking, etc. Anhedonia is the inability to experience pleasure.