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The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone. Which of the following actions should the nurse take? Select all that apply.
- A. Administer vasopressin.
- B. Implement seizure precautions.
- C. Perform frequent neurological checks.
- D. Keep a strict record of fluid intake and output.
- E. Maintain an IV infusion of 0.9% sodium chloride.
Correct Answer: B,C,D
Rationale: Seizure precautions (B), neurological checks (C), and strict I&O (D) manage SIADH complications like hyponatremia. Vasopressin (A) worsens SIADH, and normal saline (E) may not correct hyponatremia.
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The clinic nurse is caring for a client who had cataract surgery with intraocular lens implantation 2 days ago. Which client report requires priority intervention?
- A. Blurry vision in the affected eye
- B. Constipation
- C. Itching in the affected eye
- D. Sleeping on 2 pillows at night
Correct Answer: C
Rationale: Itching in the affected eye (C) may indicate infection or complications post-cataract surgery, requiring immediate intervention. Blurry vision (A) is expected initially, constipation (B) is unrelated, and sleeping elevated (D) is appropriate.
A client with a history of increased intracranial pressure is admitted to the hospital for severe headaches. The client suddenly vomits and states, 'That's weird, I didn't even feel nauseated.' Which action should the nurse take next?
- A. Document the amount of emesis
- B. Lower the head of the bed
- C. Notify the supervising registered nurse
- D. Offer an antinausea medication
Correct Answer: C
Rationale: Sudden vomiting without nausea in increased ICP suggests worsening pressure, requiring immediate RN notification (C). Documentation (A), lowering the bed (B), and antiemetics (D) are secondary.
Which nursing diagnosis is most appropriate for a client who has Cushing's syndrome?
- A. Risk for injury related to osteoporosis
- B. Pain related to cold intolerance
- C. Risk for deficient fluid volume related to excessive loss of sodium and water secondary to polyuria
- D. Risk for injury related to postural hypotension
Correct Answer: A
Rationale: Cushing's syndrome causes cortisol excess, leading to osteoporosis and increased fracture risk, making 'Risk for injury related to osteoporosis' the most appropriate diagnosis.
The charge nurse in a long-term memory care facility is making assignments for the Alzheimer unit. Which tasks may be delegated to experienced unlicensed assistive personnel? Select all that apply.
- A. Assisting clients with bathing and hair care
- B. Evaluating safety hazards in clients' rooms
- C. Monitoring clients for behavioral changes
- D. Placing bed alarms at night for clients at risk for wandering
- E. Reporting a client's swallowing difficulties during mealtime
Correct Answer: A,D,E
Rationale: Bathing/hair care (A), placing bed alarms (D), and reporting swallowing issues (E) are within UAP scope. Evaluating hazards (B) and monitoring behavior changes (C) require nursing judgment.
The nurse is caring for a client who has a hip fracture and is placed in Buck traction. Which of the following actions should the nurse take? Select all that apply.
- A. Place the client on the affected side.
- B. Monitor the client for skin breakdown.
- C. Perform frequent neurovascular checks.
- D. Keep the affected extremity in a neutral position.
- E. Ensure that the client receives adequate pain relief.
Correct Answer: B,C,D,E
Rationale: Monitoring for skin breakdown (B), neurovascular checks (C), neutral positioning (D), and pain relief (E) are essential for Buck traction. Placing the client on the affected side (A) is incorrect as it may disrupt traction.