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. You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patients plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to as
- A. Nutritional status
- B. Potassium balance
- C. Calcium balance
- D. Fluid volume status
Correct Answer: D
Rationale: The correct answer is D: Fluid volume status. Assessment of specific gravity helps to determine the concentration of solutes in the urine, indicating the degree of hydration or dehydration. In SIADH, there is water retention leading to diluted urine, resulting in low specific gravity. Monitoring specific gravity every 4 hours is crucial in assessing the patient's fluid volume status and response to treatment.
A: Nutritional status is not directly assessed by specific gravity.
B: Potassium balance is not directly assessed by specific gravity.
C: Calcium balance is not directly assessed by specific gravity.
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You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease.
What principle should guide your assessment of the patients skin turgor?
- A. Overhydration is common among healthy older adults.
- B. Dehydration causes the skin to appear spongy
- C. Inelastic skin turgor is a normal part of aging
- D. Skin turgor cannot be assessed in patients over 70.
Correct Answer: C
Rationale: The correct answer is C: Inelastic skin turgor is a normal part of aging. As people age, their skin loses elasticity and becomes less turgid, which can affect skin turgor assessment. Skin turgor assessment is an important indicator of hydration status, and in older adults, it is normal for the skin to be less elastic. This is due to changes in collagen and elastin fibers in the skin with aging. Choices A, B, and D are incorrect because overhydration is not common among healthy older adults, dehydration causes the skin to appear tented rather than spongy, and skin turgor can still be assessed in patients over 70, although it may be less reliable due to natural changes in skin elasticity with aging.
A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?
- A. Redness at the catheter insertion site
- B. Report of headache and stiff neck
- C. Temperature of 100.1 F (37.8 C)
- D. Pain rating of 8 on a scale of 0 to 10
Correct Answer: B
Rationale: The correct answer is B: Report of headache and stiff neck. This finding indicates a potential complication of epidural anesthesia called a post-dural puncture headache, which can lead to serious consequences like meningitis or subdural hematoma. The nurse should act immediately by notifying the healthcare provider for further evaluation and management. Redness at the catheter insertion site (A) may indicate local inflammation but doesn't require immediate intervention. Temperature elevation (C) could be a sign of infection but isn't as urgent as a headache and stiff neck. Pain rating of 8 (D) is important but doesn't indicate an immediate threat to the client's health like a post-dural puncture headache.
Diagnostic testing has been ordered to differentiate between normal anion gap acidosis and high anion gap acidosis
in an acutely ill patient. What health problem typically precedes normal anion gap acidosis?
- A. Metastases
- B. Excessive potassium intake
- C. Water intoxication
- D. Excessive administration of chloride
Correct Answer: D
Rationale: The correct answer is D: Excessive administration of chloride. Normal anion gap acidosis is commonly caused by an excessive intake of chloride-containing solutions like normal saline during treatment. This leads to an increase in the plasma chloride concentration, causing a decrease in the anion gap. Metastases (A) are not typically associated with normal anion gap acidosis. Excessive potassium intake (B) would not lead to normal anion gap acidosis but rather hyperkalemia. Water intoxication (C) can lead to dilutional hyponatremia but not normal anion gap acidosis.
The nurse is assessing the patient for the presence of a Chvosteks sign. What electrolyte imbalance would a
positive Chvosteks sign indicate?
- A. Hypermagnesemia
- B. Hyponatremia
- C. Hypocalcemia
- D. Hyperkalemia
Correct Answer: C
Rationale: Step 1: Chvostek's sign is a facial muscle spasm induced by tapping the facial nerve in hypocalcemia.
Step 2: Hypocalcemia causes increased neuromuscular excitability, leading to Chvostek's sign.
Step 3: Hyperkalemia (choice D) causes muscle weakness, not muscle spasm.
Step 4: Hyponatremia (choice B) affects osmolarity, not neuromuscular excitability.
Step 5: Hypermagnesemia (choice A) causes muscle weakness, not muscle spasm.
. A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern?
- A. The catheter has been in place for 20 hours.
- B. . The client has poor vascular access in the upper extremities.
- C. The catheter is placed in the proximal tibia.
- D. The clients left lower extremity is cool to the touch.
Correct Answer: D
Rationale: The correct answer is D. A cool lower extremity can indicate impaired circulation due to the intraosseous catheter placement, leading to compartment syndrome or tissue necrosis. This finding requires immediate intervention to prevent serious complications. Choices A, B, and C are incorrect because the duration of catheter placement, poor vascular access, and the specific location of the catheter do not directly impact circulation and tissue perfusion as significantly as a cool lower extremity.