Nokea
The client develops SIADH secondary to a pituitary tumor. The client's assessment findings include thirst, weight gain, fatigue, and a serum sodium of 127 mEq/L. Which intervention, if prescribed, should the nurse implement to treat SIADH?
- A. Elevate the head of the bed 30 degrees
- B. Administer vasopressin intravenously (IV)
- C. Restrict fluids to 800 to 1000 mL per day
- D. Give 0.3% sodium chloride IV infusion
Correct Answer: C
Rationale: Fluid restriction to 800-1000 mL/day treats mild SIADH with serum sodium >125 mEq/L by raising sodium concentration.
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Which statement by the client provides the best evidence that the client understands the principle of an exchange list for meal planning?
- A. I can eat one serving from each category on the exchange list per day.
- B. I record the patient's disease of food in each category are equal to one another.
- C. The number of servings from the exchange list is unlimited.
- D. I need to use the exchange list to determine the nutrition in food.
Correct Answer: B
Rationale: The exchange list groups foods with similar nutritional content, allowing equivalent substitutions.
Which statement provides the best evidence that the client who has undergone a bilateral adrenalectomy understands the postoperative course?
- A. I should avoid people with infectious diseases.
- B. I need to limit my fluid intake to 1 quart per day.
- C. My appearance will never be the same as it was before.
- D. No other treatment is necessary after I recover from surgery.
Correct Answer: A
Rationale: Avoiding infections is critical post-adrenalectomy due to lifelong steroid replacement and immunosuppression.
The concepts of nutrition and metabolism have been identified for the client. Which referral should the nurse include in the plan of care?
- A. Physical therapy.
- B. Social work.
- C. Speech therapy.
- D. Dietary.
Correct Answer: D
Rationale: A dietary referral addresses nutrition and metabolism, optimizing dietary management for conditions like diabetes. Other referrals are unrelated.
The client has developed iatrogenic Cushing's disease. Which statement is the scientific rationale for the development of this diagnosis?
- A. The client has an autoimmune problem causing the destruction of the adrenal cortex.
- B. The client has been taking steroid medications for an extended period for another disease process.
- C. The client has a pituitary gland tumor causing the adrenal glands to produce too much cortisol.
- D. The client has developed an adrenal gland problem for which the health-care provider does not have an explanation.
Correct Answer: B
Rationale: Iatrogenic Cushing’s results from prolonged exogenous steroid use, mimicking endogenous hypercortisolism. Autoimmune issues, pituitary tumors, and idiopathic causes are incorrect.
The nurse is planning the care of a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should be implemented? Select all that apply.
- A. Restrict fluids per health-care provider order.
- B. Assess level of consciousness every two (2) hours.
- C. Provide an atmosphere of stimulation.
- D. Monitor urine and serum osmolality.
- E. Weigh the client every three (3) days.
Correct Answer: A,B,D
Rationale: Fluid restriction, frequent consciousness checks, and osmolality monitoring manage SIADH’s hyponatremia and fluid overload. Stimulation is inappropriate, and weighing every 3 days is too infrequent.