A client with a closed head injury demonstrates signs of syndrome of inappropriate antidiuretic hormone (SIADH). Which additional finding should the nurse expect to obtain?
Weight gain of 2 pounds (0.91 kg) in one day.
Fremitus over the chest wall.
Serum sodium of 150 mEq/L (150 mmol/L).
Urine specific gravity of 1.004.
The Correct Answer is A
Choice A reason: Weight gain of 2 pounds (0.91 kg) in one day is a sign of fluid retention, which occurs in SIADH due to excessive secretion of antidiuretic hormone (ADH). ADH causes the kidneys to reabsorb water and reduce urine output, leading to hyponatremia and hypervolemia.
Choice B reason: Fremitus over the chest wall is a sign of increased vibration or air movement in the lungs, which can indicate pneumonia, bronchitis, or pleural effusion. These are not related to SIADH, but may be complications of head injury or fluid overload.
Choice C reason: Serum sodium of 150 mEq/L (150 mmol/L) is a sign of hypernatremia, which is a high level of sodium in the blood. This is the opposite of what happens in SIADH, where sodium levels are low due to dilution by excess water.
Choice D reason: Urine specific gravity of 1.004 is a sign of diluted urine, which indicates low concentration of solutes in the urine. This is also the opposite of what happens in SIADH, where urine is concentrated and has a high specific gravity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["100"]
Explanation
To answer this question, we need to find the rate of infusion in milliliters per hour (mL/hr) that will deliver 1 liter (1000 mL) of 0.9% sodium chloride, USP intravenously (IV) over 10 hours. We can use the following formula to calculate the rate:
Rate(mL/hr)=Volume(mL)/Time(hr)
Plugging in the given values, we get:
Rate(mL/hr)=1000mL/10hr
Simplifying, we get:
Rate= 100mL/hr
Correct Answer is A
Explanation
Choice A reason: This is correct because performing a bedside pregnancy test is the intervention that should be implemented immediately by the nurse. This is to confirm or rule out pregnancy and inform the surgical team of any possible risks or complications that may affect the client or the fetus.
Choice B reason: This is incorrect because continuing with surgery as scheduled is not an appropriate intervention without verifying the pregnancy status of the client. Surgery may pose serious threats to both maternal and fetal health, such as bleeding, infection, anesthesia complications, or miscarriage.
Choice C reason: This is incorrect because calculating gestation from last menstrual cycle is not an accurate or reliable method of determining pregnancy. The menstrual cycle can vary widely among women and may be affected by various factors such as stress, illness, or medication.
Choice D reason: This is incorrect because notifying the surgical team to cancel the surgery is not a necessary intervention unless pregnancy is confirmed. Appendicitis is a medical emergency that requires prompt surgical treatment to prevent rupture, peritonitis, or sepsis.
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