A nurse is caring for a client who is exhibiting manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse report to the provider? (Select all that apply.)

Client has increased urine specific gravity.

Changes in the client's behavior.

Client is complaining of nausea.

Client is complaining of severe headache.

Client's urine output is only 50 cc/hr.

Answer and Explanation

Correct Answer : A,B,C,D

A. Client has increased urine specific gravity: Increased urine specific gravity indicates concentrated urine, which is a hallmark of SIADH and should be reported as it reflects the excessive retention of water.

B. Changes in the client's behavior: Behavioral changes can be indicative of hyponatremia, a serious complication of SIADH, and should be reported immediately.

C. Client is complaining of nausea: Nausea is a symptom of hyponatremia, which is a common and dangerous consequence of SIADH that needs prompt attention.

D. Client is complaining of severe headache: A severe headache can also be a sign of hyponatremia and potential cerebral edema, both of which are critical conditions needing urgent intervention.

E. Client's urine output is only 50 cc/hr: While reduced urine output can be associated with SIADH, 50 cc/hr is not extremely low and might not be immediately alarming on its own. The other symptoms are more critical and should take precedence in reporting to the provider.

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Correct Answer is ["A","B","D","E"]

Explanation

A. Elevating the head of the bed 30 to 45 degrees helps prevent aspiration, which is a risk factor for ventilator-associated pneumonia.
B. Performing hand hygiene before touching the ventilator tubing is crucial to prevent the introduction of pathogens into the ventilator system.
C. Refraining from suctioning the client is incorrect; suctioning should be performed as needed to keep the airway clear.
D. Providing mouth care every 2-4 hours can reduce the risk of pathogens entering the lower respiratory tract.
E. Performing hand hygiene before touching the client reduces the risk of transmitting infectious agents to the client.

A. Dyspnea B. Malaise C. Fever D. Anorexia

Correct Answer is A

Explanation

A. Dyspnea: Worsening dyspnea may indicate complications such as heart failure or embolization of infectious material to the lungs, which can occur in infective endocarditis as a result of vegetation formation on heart valves. Dyspnea can suggest decreased cardiac output or pulmonary involvement, indicating a worsening condition.

B. Malaise: Malaise is a nonspecific symptom that is common in infective endocarditis due to systemic infection and inflammation. While it can be present in both mild and severe cases, it may not specifically indicate worsening of the condition without other signs of deterioration.

C. Fever: Fever is a hallmark symptom of infective endocarditis and may persist or worsen with progressive infection. However, fever alone may not necessarily indicate worsening if the client is already febrile due to the underlying infection.

D. Anorexia: Anorexia or loss of appetite can occur in infective endocarditis due to systemic illness but may not specifically indicate worsening without other signs of deterioration. It is important to assess for other signs of worsening condition, such as hemodynamic instability or embolic events, in conjunction with anorexia.

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A nurse is caring for a client who is exhibiting manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse report to the provider? (Select all that apply.)

Nursing Test Bank

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