A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?
Measure ankle circumference.
Obtain serum creatinine levels daily.
Ensure client takes a diuretic every morning.
Monitor daily sodium intake.
The Correct Answer is C
Rationale
A. This intervention is important for assessing peripheral edema, which can indicate fluid overload. While relevant, it is not the highest priority in addressing acute weight gain and elevated blood pressure.
B. Daily monitoring of serum creatinine is important but is more relevant once diuretic therapy is initiated to assess renal function and electrolyte balance.
C. This option is crucial because diuretic therapy is aimed at correcting fluid imbalance in SIADH. However, the timing and dosage of diuretics should be adjusted based on clinical assessment and not solely on a fixed morning administration.
D. Monitoring sodium intake is a long-term strategy in managing SIADH to prevent hyponatremia. While important, it does not address the immediate concerns of fluid overload and elevated blood pressure.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}
Explanation
After listening to the client's symptoms, the nurse realizes that she likely has acute stress disorderrelated to traumatic stress
Acute Stress Disorder: This diagnosis fits because the client is experiencing significant distress and anxiety related to the traumatic event (her house collapsing during a hurricane). Acute stress disorder is characterized by intrusive thoughts, nightmares, flashbacks, and avoidance behaviors following exposure to a traumatic event. The client's symptoms of persistent thoughts about the event, difficulty sleeping due to these thoughts, and feeling unable to return to her previous emotional state ("funk") are indicative of acute stress disorder.
Traumatic Stress: This describes the source of the client's symptoms. The collapse of her house during a hurricane is a traumatic event that has triggered her acute stress disorder symptoms. Traumatic stress refers to the psychological and emotional response to a deeply distressing or disturbing event.
Correct Answer is D
Explanation
Rationale
A. Ear pain is not typically a common symptom of mononucleosis. Fever, however, is commonly seen in mononucleosis due to the body's immune response to the viral infection.
B. In mononucleosis, there is often an increase in white blood cells (specifically lymphocytes) and an elevated sedimentation rate (ESR). These changes reflect the body's immune response to the Epstein- Barr virus infection.
C. Increased blood urea nitrogen (BUN) and serum creatinine levels are not typically associated with mononucleosis. These markers are more indicative of kidney function and are not directly affected by the viral infection causing mononucleosis.
D. A positive test for Epstein-Barr virus (EBV) antibodies is diagnostic for mononucleosis. Malaise, which is a general feeling of discomfort or illness, is a hallmark symptom of mononucleosis along with other systemic symptoms like fatigue, sore throat, swollen lymph nodes, and sometimes a rash.
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