Nokea
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.
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The client develops acne. What should the nurse instruct the client with acne?
- A. Use water-based cosmetics or creams.
- B. Do not receive live virus vaccines.
- C. Avoid the use of alcohol while taking the drug.
- D. Avoid exposure to infections.
Correct Answer: A
Rationale: The nurse should instruct the client with acne to keep the affected areas clean and use over-the-counter acne drugs and water-based cosmetics or creams. The nurse need not instruct the client to stop receiving live virus vaccines, avoid using alcohol, or avoid exposure to infections. When the client is undergoing long-term or high-dose glucocorticoid therapy, the nurse should inform the client to avoid receiving live virus vaccines and avoid exposure to infections if possible in the teaching plan for the client and family. If the client is undergoing vasopressin therapy, the nurse needs to instruct the client to avoid the use of alcohol while taking the drug.
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.
Which of the following hormones are secreted by the adrenal gland? Select all that apply.
- A. Growth hormone
- B. Mineralocorticoids
- C. Glucocorticoids
- D. Prolactin
- E. Oxytocin
Correct Answer: B,C
Rationale: Glucocorticoids and mineralocorticoids are secreted by the adrenal gland. Growth hormone, prolactin, and oxytocin are secreted by the pituitary gland.
A nurse is caring for a client receiving desmopressin (DDAVP). The nurse would assess the client for which of the following adverse reactions? Select all that apply.
- A. Tremor
- B. Hypotension
- C. Diaphoresis
- D. Dehydration
- E. Nausea
Correct Answer: A,C,E
Rationale: A nurse should monitor a client taking desmopressin (DDAVP) for the following adverse reactions: tremor, diaphoresis, vertigo, nasal congestion, nausea, vomiting, abdominal cramps, and water intoxication.
A nurse is caring for a client with nocturnal enuresis. A physician has prescribed desmopressin acetate to the client. The nurse would assess the client for which of the following as a possible adverse reaction?
- A. Nasal congestion
- B. Breast tenderness
- C. Fluid retention
- D. Gynecomastia
Correct Answer: A
Rationale: The nurse should monitor for nasal congestion, abdominal cramps, headache, and nausea in the client as the adverse reactions to desmopressin acetate. When the client is administered gonadotropin, the nurse needs to monitor for fluid retention and gynecomastia as the adverse reactions to the drug. When choriogonadotropin alfa is administered to the client, the nurse should monitor for breast tenderness, ovarian overstimulation, and vasomotor flushes as the adverse reactions to the drug.