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A client with diabetes insipidus is extremely dehydrated and is unable to take oral fluids. Fluid therapy is prescribed. Which intervention would be most important for the client?
- A. Measuring the urine output every 30 minutes
- B. Monitoring the rate of IV infusions
- C. Measuring the fluid intake
- D. Weighing the client daily
Correct Answer: A
Rationale: The nurse must measure the urine output every 30 minutes when administering prescribed fluid and drug therapy when the client is acutely ill or extremely dehydrated, fails to take oral fluids, or is beginning to receive medical treatment. Doing so ensures adequate kidney function. Although monitoring the rate of IV infusions, measuring fluid intake, and weighing the client daily are important, measuring the urine output every 30 minutes is the priority.
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The nurse is reviewing the laboratory and diagnostic test findings of a client diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which of the following would the nurse expect to find?
- A. Elevated serum sodium levels
- B. Decreased serum osmolarity
- C. Decreased urine sodium levels
- D. Elevated urine calcium levels
Correct Answer: B
Rationale: With SIADH, serum sodium levels and serum osmolarity are decreased. Urine sodium levels and osmolarity are high. Calcium levels are not involved with this disorder.
The nurse is teaching a client about the dietary restrictions related to a diagnosis of hyperparathyroidism. What foods should the nurse encourage the client to avoid?
- A. Bananas
- B. Chicken livers
- C. Hamburger
- D. Milk
Correct Answer: D
Rationale: Clients with hyperparathyroidism should use a low-calcium diet (fewer dairy products) and drink at least 3 to 4 L of fluid daily to dilute the urine and prevent renal stones from forming. It is especially important that the client drink fluids before going to bed and periodically throughout the night to avoid concentrated urine. Bananas, chicken livers, and hamburgers do not require avoidance. Milk is the highest in calcium content.
A client with acromegaly is admitted to the hospital with complaints of partial blindness that began suddenly. What does the nurse suspect is occurring with this client?
- A. Glaucoma
- B. Corneal abrasions
- C. Retinal detachment
- D. Pressure on the optic nerve
Correct Answer: D
Rationale: Partial blindness may result from pressure on the optic nerve. Glaucoma does not occur suddenly, and the client did not report injury to suspect corneal abrasions or retinal detachment.
A client with Addison disease has a blood glucose level above 80 mg/dL 30 minutes after receiving 15 g of carbohydrates for symptoms of hypoglycemia. Which action would the nurse take next?
- A. Inform the physician immediately.
- B. Give the client milk and graham crackers.
- C. Instruct the client to remain in bed.
- D. Check the client's blood glucose level before each meal.
Correct Answer: B
Rationale: Milk and graham crackers contain forms of carbohydrates that take longer to absorb and tend to maintain the blood glucose level for an extended period. The physician should be informed if the client continues to be symptomatic and the blood glucose level is below 80 mg/dL. Maintaining bed rest protects the client from injuries from a fall but does not address the blood glucose issue. Assessing the client's blood glucose level provides a numeric assessment of the blood glucose level and would be performed in an ongoing fashion.
A client is scheduled for a hypophysectomy for the management of a pituitary tumor. What is the nurse priority when caring for this client? Select all that apply.
- A. Assure the client that he will make it through the surgery without any difficulty.
- B. Help the client cope with changes in physical appearance.
- C. Pace activities to accommodate the client's fatigue.
- D. Relieve discomfort from headaches, abdominal distention, and skeletal pain.
- E. Encourage self-care and activities as client's endurance permits.
Correct Answer: B,C,D,E
Rationale: Until the client has surgery or receives radiation treatment, nursing priorities include helping the client cope with changes in physical appearance; pacing activities to accommodate the client's fatigue; and relieving discomfort from headaches, abdominal distention resulting from organ enlargement, and skeletal pain. Assuring the client that he will make it through the surgery without any difficulty is not appropriate as it dismisses the client's concerns and does not address specific care priorities.