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A nurse completing discharge counseling should advise a client taking vasopressin (Pressyn) to notify the physician if which of the following occur? Select all that apply.
- A. Changes in urine output
- B. Abdominal cramps
- C. Skin blanching
- D. Diarrhea
- E. Cough
Correct Answer: A,B,C
Rationale: A nurse completing discharge counseling should advise a client taking vasopressin (Pressyn) to notify the physician if any of the following occur: a significant increase or decrease in urine output, abdominal cramps, skin blanching, nausea, confusion, headache, drowsiness, or signs of inflammation or infection at the injection sites.
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A nurse is assessing a client who is receiving desmopressin therapy and suspects that the client is experiencing water intoxication. Which of the following would support the nurse's suspicions? Select all that apply.
- A. Drowsiness
- B. Headache
- C. Confusion
- D. Abdominal pain
- E. Diarrhea
Correct Answer: A,B,C
Rationale: Symptoms of water intoxication include drowsiness, listlessness, confusion, and headache (which may precede convulsions and coma). Abdominal pain and diarrhea are not associated with water intoxication.
A client is receiving corticosteroid therapy. Which nursing diagnosis would the nurse be least likely to identify for this client?
- A. Risk for Infection
- B. Disturbed Body Image
- C. Risk for Injury
- D. Deficient Fluid Volume
Correct Answer: D
Rationale: A client who is receiving corticosteroid therapy would be least likely to have a nursing diagnosis of Deficient Fluid Volume. Rather, Excess Fluid Volume would be more appropriate. Risk for Infection related to immunosuppression, Disturbed Body Image related to cushingoid effects, and Risk for Injury related to muscle atrophy and osteoporosis would be appropriate.
Which of the following hormones would the instructor include as being secreted by the anterior pituitary gland? Select all that apply.
- A. Growth hormone
- B. Adrenocorticotropic hormone
- C. Vasopressin
- D. Prolactin
- E. Oxytocin
Correct Answer: A,B,D
Rationale: Prolactin, adrenocorticotropic hormone, growth hormone, luteinizing hormone, follicle-stimulating hormone, and thyroid-stimulating hormone are secreted by the anterior pituitary gland. Vasopressin and oxytocin are secreted by the posterior pituitary gland.
A physician has prescribed vasopressin to the client for regulating the reabsorption of water by the kidneys. Which of the following assessments should the nurse perform after the administration of vasopressin?
- A. Observe for and report any evidence of edema, such as dyspnea.
- B. Measure and record the client's abdominal girth every hour.
- C. Observe the client for blanching of the skin, abdominal cramps, and nausea.
- D. Weigh the client every day to obtain a baseline weight.
Correct Answer: C
Rationale: After vasopressin is administered to the client, the nurse should observe the client every 10 to 15 minutes for signs of an excessive dosage, which include blanching of the skin, abdominal cramps, and nausea. After corticotropin is administered to the client, the nurse needs to observe for and report any evidence of edema, such as weight gain, rales, increased pulse or dyspnea, or swollen extremities. If the client is receiving vasopressin for abdominal distention, the nurse needs to auscultate the abdomen every 15 to 30 minutes and measure abdominal girth hourly. The nurse needs to weigh the client to obtain a baseline weight for future comparison before administering vasopressin to the client.
A nurse would administer vasopressin (Pressyn) cautiously to a client with which of the following? Select all that apply.
- A. Sleep apnea
- B. Migraine headaches
- C. Asthma
- D. Seizure disorders
- E. Angina
Correct Answer: B,C,D,E
Rationale: Vasopressin (Pressyn) is used cautiously in clients with a history of seizure disorder, migraine headaches, asthma, congestive heart failure, or vascular disease (angina and myocardial infarction).