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The nurse is admitting a patient with possible syndrome of inappropriate antidiuretic hormone (SIADH) due to a head trauma. Which of the following information obtained by the nurse is most important to communicate rapidly to the health care provider?
- A. The patient complains of dyspnea with activity.
- B. The patient has a urine specific gravity of 1.025.
- C. The patient has a recent weight gain of 5.6 kg.
- D. The patient has a serum sodium level of 119 mmol/L.
Correct Answer: D
Rationale: A serum sodium of less than 120 mmol/L increases the risk for complications such as seizures and needs rapid correction. The other data are not unusual for a patient with SIADH and do not indicate the need for rapid action.
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The nurse is caring for a patient with Graves' disease who has to,2026. 11:3.29. following actionspl. All is included in the plan of care?
- A. Apply eye patches to protect the cornea from irritation.
- B. Place cold packs on the eyes to
- C. Elevate the head of the patient's bed to reduce periorbital
- D. Teach the patient to blink every few seconds to lubric
Correct Answer: C
Rationale: The patient should sit upright as much as possible to promote fluid drainage from the periorbital area. With exophthalmos, the patient is unable to close the eyes completely. Lubrication of the eyes, rather than eye patches, will protect the eyes from developing corneal scarring. The swelling of the eye is not caused by excessive blood flow to the eye, so cold packs will not be helpful.
The nurse is caring for a patient with Cushing's syndrome who returns to the surgical unit following an adrenalectomy. Which of the following actions during the initial postoperative period has the highest priority?
- A. Monitoring for infection
- B. Protecting the patient's skin
- C. Maintaining fluid and electrolyte status
- D. Preventing severe emotional disturbances
Correct Answer: C
Rationale: After adrenalectomy, the patient is at risk for circulatory instability caused by fluctuating hormone levels, and the focus of care is to assess and maintain fluid and electrolyte status through the use of IV fluids and corticosteroids. The other goals are also important for the patient but are not as immediately life-threatening as the circulatory collapse that can occur with fluid and electrolyte disturbances.
The nurse is caring for a patient in a long-term care facility who has these medications prescribed. After the patient is diagnosed with hypothyroidism, which of the following medications should the nurse report to the health care provider?
- A. Docusate
- B. Diazepam
- C. Ibuprofen
- D. Cefoxitin
Correct Answer: B
Rationale: Worsening of mental status and myxedema coma can be precipitated by the use of sedatives, especially in older persons. The nurse should discuss the diazepam with the health care provider before administration. The other medications may be given safely to the patient.
The nurse is caring for a patient with inappropriate antidiuretic hormone (SIADH) due to a head trauma who is receiving a hypertonic saline IV solution to counteract hyponatremia. The nurse will expect the saline solution to be administered until the patient's serum sodium reaches which of the following levels?
- A. 120 mmol/L.
- B. 130 mmol/L.
- C. 128 mmol/L.
- D. 138 mmol/L.
Correct Answer: C
Rationale: If the patient is hyponatremic, hypertonic saline may be administered until the serum sodium level reaches at least 130 mmol/L. Hypernatremia is evident with a sodium level of 168 mmol/L.
After receiving change-of-shift report, which of the following four patients should the nurse assess first?
- A. A 31-year-old with Cushing's syndrome and a blood glucose level of 13.7 mmol/L.
- B. A 22-year-old admitted with syndrome of inappropriate antidiuretic hormone (SIADH) who has a serum sodium level of 130 mmol/L.
- C. A 70-year-old who recently started taking levothyroxine and has an irregular pulse of 134
- D. A 53-year-old who has Addison's disease and is due for a scheduled dose of hydrocortisone.
Correct Answer: C
Rationale: Initiation of thyroid replacement in older adults may cause angina and cardiac dysrhythmias. The patient's high pulse rate needs rapid investigation by the nurse to assess for and intervene with any cardiac problems. The other patients also require nursing assessment and/or actions but are not at risk for life-threatening complications.