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A patient with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) is being cared for on the critical care unit. The priority nursing diagnosis for a patient with this condition is what?
- A. Risk for peripheral neurovascular dysfunction
- B. Excess fluid volume
- C. Hypothermia
- D. Ineffective airway clearance
Correct Answer: B
Rationale: The priority nursing diagnosis for a patient with SIADH is excess fluid volume, as the patient retains fluids and develops a sodium deficiency. Restricting fluid intake is a typical intervention for managing this syndrome. Temperature imbalances are not associated with SIADH. The patient is not at risk for neurovascular dysfunction or a compromised airway.
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A patient has returned to the floor after having a thyroidectomy for thyroid cancer. The nurse knows that sometimes during thyroid surgery the parathyroid glands can be injured or removed. What laboratory finding may be an early indication of parathyroid gland injury or removal?
- A. Hyponatremia
- B. Hypophosphatemia
- C. Hypocalcemia
- D. Hypokalemia
Correct Answer: C
Rationale: Injury or removal of the parathyroid glands may produce a disturbance in calcium metabolism and result in a decline of calcium levels (hypocalcemia). As the blood calcium levels fall, hyperirritability of the nerves occurs, with spasms of the hands and feet and muscle twitching. This group of symptoms is known as tetany and must be reported to the physician immediately, because laryngospasm may occur and obstruct the airway. Hypophosphatemia, hyponatremia, and hypokalemia are not expected responses to parathyroid injury or removal. In fact, parathyroid removal or injury that results in hypocalcemia may lead to hyperphosphatemia.
The nurse is caring for a patient at risk for an addisonian crisis. For what associated signs and symptoms should the nurse monitor the patient? Select all that apply.
- A. Epistaxis
- B. Pallor
- C. Rapid respiratory rate
- D. Bounding pulse
- E. Hypotension
Correct Answer: B,C,E
Rationale: The patient at risk is monitored for signs and symptoms indicative of addisonian crisis, which can include shock; hypotension; rapid, weak pulse; rapid respiratory rate; pallor; and extreme weakness. Epistaxis and a bounding pulse are not symptoms or signs of an addisonian crisis.
The nurse is assessing a patient diagnosed with Graves disease. What physical characteristics of Graves disease would the nurse expect to find?
- A. Hair loss
- B. Moon face
- C. Bulging eyes
- D. Fatigue
Correct Answer: C
Rationale: Clinical manifestations of the endocrine disorder Graves disease include exophthalmos (bulging eyes) and fine tremor in the hands. Graves disease is not associated with hair loss, a moon face, or fatigue.
A patient is prescribed corticosteroid therapy. What would be priority information for the nurse to give the patient who is prescribed long-term corticosteroid therapy?
- A. The patients diet should be low protein with ample fat
- B. The patient may experience short-term changes in cognition
- C. The patient is at an increased risk for developing infection
- D. The patient is at a decreased risk for development of thrombophlebitis and thromboembolism
Correct Answer: C
Rationale: The patient is at increased risk of infection and masking of signs of infection. The cardiovascular effects of corticosteroid therapy may result in development of thrombophlebitis or thromboembolism. Diet should be high in protein with limited fat. Changes in appearance usually disappear when therapy is no longer necessary. Cognitive changes are not common adverse effects.
Following an addisonian crisis, a patients adrenal function has been gradually regained. The nurse should ensure that the patient knows about the need for supplementary glucocorticoid therapy in which of the following circumstances?
- A. Episodes of high psychosocial stress
- B. Periods of dehydration
- C. Episodes of physical exertion
- D. Administration of a vaccine
Correct Answer: A
Rationale: During stressful procedures or significant illnesses, additional supplementary therapy with glucocorticoids is required to prevent addisonian crisis. Physical activity, dehydration and vaccine administration would not normally be sufficiently demanding such to require glucocorticoids.