Nokea
The nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH). The nurse notices that the client has become confused and extremely short of breath, and crackles are heard when lungs are auscultated. What is the first action by the nurse?
- A. Administer a diuretic.
- B. Notify the physician.
- C. Lay the client flat.
- D. Suction the client.
Correct Answer: B
Rationale: The nurse closely monitors fluid intake and output and vital signs. The nurse carefully assesses LOC and immediately reports any changes to the physician. The nurse checks closely for signs of fluid overload (confusion, dyspnea, pulmonary congestion, hypertension) and hyponatremia (weakness, muscle cramps, anorexia, nausea, diarrhea, irritability, headache, weight gain without edema). Laying the client flat would increase the shortness of breath and would deoxygenate the client. The nurse cannot administer a diuretic without the physician's order. Suctioning of the client will not clear the airway at this time.
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The nurse is providing education to a client who will be having a hypophysectomy. What should the nurse be sure to include to prevent complications?
- A. Perform exercises involving bending at the hips
- B. Avoid sneezing and coughing
- C. Blow nose to clear the cold when packing is removed.
- D. Drink all liquids through a straw.
Correct Answer: B
Rationale: The nurse should instruct the client to avoid sneezing and coughing postoperatively. If the client has nasal packing, the nurse monitors drainage from the nose and postnasal drainage for the presence of cerebrospinal fluid. The nurse should remind the client to avoid drinking from a straw, sneezing, coughing, blowing the nose, and bending over to prevent dislodging the graft that seals the operative area between the cranium and nose.
The nurse is caring for a client with hypoparathyroidism. When the nurse taps the client's facial nerve, the client's mouth twitches and the jaw tightens. What is this response documented as related to the low calcium levels?
- A. Positive Chvostek sign
- B. Positive Trousseau sign
- C. Positive paresthesia
- D. Positive Babinski sign
Correct Answer: A
Rationale: If a nurse taps the client's facial nerve (which lies under the tissue in front of the ear), the client's mouth twitches and the jaw tightens. The response is identified as a positive Chvostek sign. A positive Trousseau sign is elicited by placing a BP cuff on the upper arm, inflating it between the systolic and diastolic BP, and waiting 3 minutes. The nurse observes the client for spasm of the hand (carpopedal spasm), which is evidenced by the hand flexing inward. Positive Babinski sign is elicited by stroking the sole of the foot. Paresthesia is not a symptom that can be elicited; it is felt by the client.
A client with acromegaly is complaining of severe headaches. What does the nurse suspect is the cause of the headaches that is related to the acromegaly?
- A. A pituitary tumor
- B. A decrease in release in the growth hormone
- C. A decrease in the glucose level
- D. An increase in cerebral edema
Correct Answer: A
Rationale: When the overgrowth is from a tumor, headaches caused by pressure on the sella turcica, a bony depression in which the pituitary gland rests, are common. There is actually an increase in the secretion of the growth hormone. The headaches would not be caused by decreases in glucose levels. The client does not have cerebral edema.
A client with syndrome of inappropriate antidiuretic hormone (SIADH) is severely hyponatremic. What IV fluids would the nurse anticipate administering to this client?
- A. 3% hypertonic sodium chloride solution
- B. Lactated Ringer's solution
- C. 5% dextrose in water
- D. 0.9% sodium chloride solution
Correct Answer: A
Rationale: Severe hyponatremia is treated with IV administration of a 3% hypertonic sodium chloride solution. The other answers will not provide the amount of sodium required to correct the hyponatremia.
A client with severe hypoparathyroidism is experiencing tetany. What medication, prescribed by the physician for emergency use, will the nurse administer to correct the deficit?
- A. Sodium bicarbonate
- B. Fludrocortisone
- C. Calcium gluconate
- D. Methylprednisolone
Correct Answer: C
Rationale: Tetany and severe hypoparathyroidism are treated immediately by the administration of an IV calcium salt, such as calcium gluconate. The other medications are not effective for the treatment of calcium deficit.