Nokea
The nurse is admitting a client to rule out aldosteronism. Which assessment data support the client's diagnosis?
- A. Temperature.
- B. Pulse.
- C. Respirations.
- D. Blood pressure.
Correct Answer: D
Rationale: Elevated blood pressure is a hallmark of aldosteronism due to sodium retention and fluid overload. Temperature, pulse, and respirations are less specific.
You may also like to solve these questions
Which assessment data indicate the client diagnosed with diabetic ketoacidosis is responding to the medical treatment?
- A. The client has tented skin turgor and dry mucous membranes.
- B. The client is alert and oriented to date, time, and place.
- C. The client's ABG results are pH 7.29, PaCO2 44, HCO3 15.
- D. The client's serum potassium level is 3.3 mEq/L.
Correct Answer: B
Rationale: Alertness and orientation indicate resolving DKA, as cerebral function improves. Persistent dehydration, acidosis (pH 7.29), and hypokalemia are not signs of improvement.
The nurse determined that the client's fluid volume deficit from HHNS has resolved. Which serum laboratory finding led to the nurse's conclusion?
- A. Decreased glucose
- B. Decreased sodium
- C. Decreased osmolality
- D. Decreased potassium
Correct Answer: C
Rationale: A normalizing of the serum osmolality indicates that the fluid volume deficit is resolving.
The nurse obtains a fingerstick blood glucose reading of 48 mg/dL for the client with type 1 DM. The client is to receive 6 units of regular and 10 units of NPH insulin now. Which is the nurse's best immediate intervention?
- A. Administer the insulin that is due now.
- B. Call the lab for a STAT serum glucose level.
- C. Have the client choose foods for a meal now.
- D. Provide juice with 15 grams of carbohydrates.
Correct Answer: D
Rationale: Hypoglycemia is treated with 15 to 20 g of a simple (fast-acting) carbohydrate, such as 4 to 6 oz of fruit juice or 8 oz of low-fat milk.
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.
Which action by the nurse provides the best data for monitoring the client's therapeutic response to sodium restriction?
- A. Monitoring sodium intake
- B. Measuring pedal edema
- C. Assessing skin turgor
- D. Weighing the client
Correct Answer: B
Rationale: Measuring pedal edema assesses fluid retention, a key indicator of sodium restriction response in Cushing's syndrome.