A nurse is caring for a client with chronic kidney disease (CKD) who has elevated intracranial pressure (ICP). While assessing the client, the nurse hears crackles in the lungs and notes a decrease in urine output.Which complication has the client likely developed?

Post-renal acute kidney injury (AKI).

Diabetes insipidus (DI).

Syndrome of inappropriate antidiuretic hormone (SIADH).

Congestive heart failure (CHF).

Answer and Explanation

The Correct Answer is D

Choice A rationale
Post-renal acute kidney injury (AKI) is caused by obstruction of urine flow, leading to decreased urine output, but it does not typically cause crackles in the lungs.
Choice B rationale
Diabetes insipidus (DI) is characterized by excessive urination and thirst due to a deficiency of antidiuretic hormone (ADH), but it does not cause crackles in the lungs.
Choice C rationale
Syndrome of inappropriate antidiuretic hormone (SIADH) involves excessive release of ADH, leading to water retention and hyponatremia, but it does not cause crackles in the lungs.
Choice D rationale
Congestive heart failure (CHF) can lead to fluid accumulation in the lungs (crackles) and decreased urine output due to poor cardiac function and renal perfusion.

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Correct Answer is B

Explanation

Choice A rationale
Nausea and vomiting can be caused by various conditions, including gastrointestinal issues and brain injuries, but they are not specifically indicative of a diffuse brain stem injury.
Choice B rationale
Nuchal rigidity, or neck stiffness, is a classic sign of meningeal irritation, often due to meningeal edema in conditions like meningitis.
Choice C rationale
Bilateral fixed and dilated pupils are more commonly associated with severe brain injury or increased intracranial pressure, not specifically a cerebellar brain attack.
Choice D rationale
Brudzinski’s sign is a physical exam finding indicative of meningeal irritation, commonly seen in bacterial meningitis, not specifically viral meningitis.

A. Administer antipyretic medication as prescribed. B. Encourage fluid intake to prevent dehydration. C. Monitor vital signs every 4 hours. D. Apply a cooling blanket to reduce fever.

Correct Answer is A

Explanation

Choice A rationale
Administering antipyretic medication as prescribed is a priority intervention for a client with a body temperature of 38°C (100.4°F). Antipyretics help reduce fever and provide comfort to the patient. They work by inhibiting the production of prostaglandins, which are involved in the fever response.
Choice B rationale
Encouraging fluid intake to prevent dehydration is also important, but it is not the priority intervention. Adequate hydration helps maintain fluid balance and supports the body’s ability to regulate temperature.
Choice C rationale
Monitoring vital signs every 4 hours is essential for assessing the patient’s condition, but it is not an intervention that directly addresses the fever. It helps track the patient’s response to treatment and detect any changes in their condition.
Choice D rationale
Applying a cooling blanket to reduce fever can be effective, but it is typically used when antipyretic medications are not sufficient or contraindicated. Cooling measures help lower body temperature through conduction and evaporation.

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A nurse is caring for a client with chronic kidney disease (CKD) who has elevated intracranial pressure (ICP). While assessing the client, the nurse hears crackles in the lungs and notes a decrease in urine output.Which complication has the client likely developed?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which pieces of information link up correctly?

Correct Answer is B

Explanation

A nurse is caring for a client with a body temperature of 38°C (100.4°F). Which of the following interventions should the nurse prioritize?

Correct Answer is A

Explanation

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