Nokea
The nurse is providing care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which laboratory result requires immediate intervention?
- A. Serum sodium of 140 mEq/L.
- B. Serum potassium of 4.5 mEq/L.
- C. Serum osmolality of 280 mOsm/kg.
- D. Serum sodium of 130 mEq/L.
Correct Answer: D
Rationale: The correct answer is D: Serum sodium of 130 mEq/L. In SIADH, there is excess release of antidiuretic hormone leading to water retention and dilutional hyponatremia. A serum sodium level of 130 mEq/L indicates severe hyponatremia, which can result in neurological symptoms, such as confusion, seizures, and coma. Therefore, immediate intervention is required to prevent further complications. Choice A, a serum sodium of 140 mEq/L, is within the normal range and does not require immediate intervention. Choice B, serum potassium of 4.5 mEq/L, is also within the normal range and is not directly related to SIADH. Choice C, serum osmolality of 280 mOsm/kg, is a measure of the concentration of solutes in the blood and may not be the most critical parameter to address in a client with SIADH and severe hyponatremia.
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A female adult walks into a local community health clinic and tells the nurse that she is homeless and cannot seem to find help. Which statement indicates to the nurse that a client is feeling separated from society and helpless?
- A. "I'm feeling really isolated from everyone and scared."
- B. "I feel like I cannot get enough food to live any longer."
- C. "I know that I will always be poor so what's the use of trying?"
- D. "People like me are never respected, no matter how well we do."
Correct Answer: A
Rationale: Choice A is the correct answer because the statement reflects a sense of isolation and helplessness, indicating a profound emotional and social disconnect. The client expresses feeling separated from others and scared, highlighting a deep emotional distress. Choices B, C, and D touch on different issues such as food insecurity, hopelessness about poverty, and lack of respect, but they do not specifically address the feelings of isolation and helplessness mentioned in the client's statement.
A male client leaves his job at a nearby restaurant and visits the health clinic where he is diagnosed with viral conjunctivitis. While receiving discharge instructions from the nurse, the client states that he is feeling much better and plans to return to work for the afternoon shift. How should the nurse respond?
- A. advise the client to wear a face mask around other people
- B. ask the client what type of work he does at the restaurant
- C. instruct the client to use dark glasses if lighting is bright
- D. explain that the client should stay home for the next few days
Correct Answer: D
Rationale: The correct answer is D: explain that the client should stay home for the next few days. Viral conjunctivitis is highly contagious, and the client should avoid close contact with others until it resolves. Returning to work while still contagious can lead to the spread of the infection to coworkers and customers. Choice A is incorrect because wearing a face mask may not provide sufficient protection against spreading the virus in a close work environment. Choice B is irrelevant to the situation as the focus should be on the client's health and preventing the spread of the infection. Choice C is also unrelated to the management of viral conjunctivitis and does not address the contagious nature of the condition.
The healthcare provider is assessing a client with a suspected pulmonary embolism. Which finding requires immediate intervention?
- A. Chest pain.
- B. Shortness of breath.
- C. Tachycardia.
- D. Cyanosis.
Correct Answer: D
Rationale: Cyanosis is a late sign of hypoxemia and indicates severe oxygen deprivation, necessitating immediate intervention in a client with a suspected pulmonary embolism. Chest pain, shortness of breath, and tachycardia are also concerning symptoms in pulmonary embolism; however, cyanosis signifies critical oxygen deficiency and warrants urgent attention to prevent further complications.
During a home visit, the nurse observes that an elderly client has numerous bruises on her arms and appears fearful of her caregiver. What should the nurse do first?
- A. report the findings to adult protective services
- B. ask the client how she got the bruises
- C. document the observations in the client's medical record
- D. discuss the observations with the caregiver
Correct Answer: B
Rationale: The initial step for the nurse should be to ask the client how she got the bruises. This approach allows the nurse to directly assess the situation, gather information from the client, and potentially uncover signs of abuse. Reporting to adult protective services should come after obtaining more details from the client to ensure appropriate action. Documenting the observations is important but should follow gathering information from the client. Discussing the observations with the caregiver may not be appropriate as the caregiver could be the source of abuse, and involving them first may jeopardize the client's safety.
A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make?
- A. How long has the client been taking the medication?
- B. Assess the client's dietary habits.
- C. Check for signs of infection.
- D. Evaluate the client's sleep pattern.
Correct Answer: A
Rationale: The correct answer is A. When a client reports drowsiness while taking clonidine, the nurse should assess how long the client has been taking the medication. Drowsiness is a common side effect that can occur in the early weeks of treatment with clonidine. By understanding the duration of medication use, the nurse can determine if the drowsiness is a temporary effect that may decrease over time. Choices B, C, and D are incorrect because assessing the client's dietary habits, checking for signs of infection, or evaluating the client's sleep pattern would not directly address the drowsiness associated with clonidine use.