Nokea
The nurse is caring for a client with the syndrome of inappropriate antidiuretic hormone (SIADH). Which assessment finding requires immediate follow-up?
- A. Disorientation
- B. High urine specific gravity
- C. Oliguria
- D. Increased thirst
Correct Answer: A
Rationale: SIADH causes water retention and hyponatremia, which can lead to disorientation—a neurological symptom requiring urgent follow-up to prevent seizures or coma. Other findings are expected.
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The nurse preceptor observes a newly hired nurse care for a client with a myxedema coma. It would require follow up by the nurse preceptor if the newly hired nurse is observed
- A. applying a cooling blanket to the client.
- B. requesting a prescription for hydrocortisone.
- C. removing the water pitcher from the bedside.
- D. placing an oral endotracheal tube at the bedside for potential use.
Correct Answer: A
Rationale: Myxedema coma is a severe hypothyroid state with hypothermia. A cooling blanket worsens this; a warming blanket is needed. Hydrocortisone addresses adrenal insufficiency, removing water prevents dilutional hyponatremia, and an endotracheal tube is prudent for potential respiratory support.
The nurse is educating a group of students on the effects of corticosteroids. It would be appropriate for the nurse to identify the following adverse effects associated with corticosteroids.
- A. Mood lability
- B. Immunosuppression
- C. Hypoglycemia
- D. Hyperkalemia
- E. Weight gain
Correct Answer: A, B, E
Rationale: Corticosteroids cause mood changes, suppress immunity, and promote weight gain via fluid retention and fat redistribution. They cause hyperglycemia, not hypoglycemia, and hypokalemia, not hyperkalemia.
The nurse is caring for a client receiving prescribed dexamethasone. Which of the following adverse reactions may occur?
- A. Infection
- B. Hypotension
- C. Peripheral edema
- D. Hypoglycemia
- E. Weight loss
- F. Insomnia
Correct Answer: A,C,F
Rationale: Dexamethasone, a corticosteroid, increases infection risk, causes fluid retention (peripheral edema), and insomnia. Hypotension, hypoglycemia, and weight loss are not typical; hypertension, hyperglycemia, and weight gain are more common.
The nurse is performing an assessment on a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which assessment findings would support the diagnosis of SIADH?
- A. Peripheral edema
- B. Excessive urine production
- C. Normal or slightly increased blood pressure
- D. Low urine specific gravity
Correct Answer: A, C
Rationale: SIADH causes water retention, leading to edema and normal or slightly elevated BP from fluid overload. Urine is concentrated (high specific gravity), not low, and output is reduced, not excessive.
The nurse is caring for a client eight hours postoperative following a total thyroidectomy. Which of the following assessment findings indicate that the client is developing a complication?
- A. Moderate amount of dried sanguineous drainage on the dressing
- B. Oral temperature of 99.2°F (37.3°C)
- C. Apical pulse of 56
- D. The client reports a sore throat when speaking
Correct Answer: A
Rationale: Excessive drainage post-thyroidectomy may indicate hemorrhage, a serious complication. A slightly elevated temperature, mild bradycardia, and sore throat are expected or less concerning in the immediate postoperative period.