The nurse is caring for a 2-year-old who is lethargic and irritable after brain tumor surgery. She is noted to have dry mucous membranes and high urinary output. She has had 2 generalized seizures in the past hour. Which of the following is likely causing these symptoms?
Hypernatremia and Diabetes Insipidus
Hyponatremia and Diabetes insipidus
Hyponatremia and Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
Hypernatremia and Syndrome of inappropriate Antidiuretic Hormone (SIADH)
The Correct Answer is A
A. Hypernatremia and Diabetes Insipidus.
The symptoms described, including dry mucous membranes, high urinary output, and seizures, are consistent with hypernatremia, which is an elevated level of sodium in the blood, and Diabetes Insipidus (DI).
Diabetes Insipidus is a condition where the body is unable to properly regulate water balance, leading to excessive thirst and urination. In the presence of DI, water loss is excessive, leading to dehydration, increased sodium levels, and potentially seizures.
B. Hyponatremia and Diabetes Insipidus: This option doesn't align with the symptom of hypernatremia (elevated sodium levels) but suggests low sodium levels (hyponatremia), which would have different symptoms.
C. Hyponatremia and Syndrome of Inappropriate Antidiuretic Hormone (SIADH): This option also suggests low sodium levels (hyponatremia) and a different condition (SIADH) characterized by water retention and dilution of the blood, which is not consistent with the described symptoms.
D. Hypernatremia and Syndrome of Inappropriate Antidiuretic Hormone (SIADH): This option suggests high sodium levels (hypernatremia) but includes SIADH, which would not result in high urinary output. SIADH is characterized by excessive retention of water, leading to low urinary output and concentrated urine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Rigid abdomen: A rigid abdomen is not a common finding in HPS. However, it is more typical in conditions such as intestinal obstruction.
B. Distended neck veins: Distended neck veins are not a typical manifestation of HPS. They may be associated with other cardiovascular or respiratory issues.
C. Red currant jelly stools: Red currant jelly-like stools are not typically seen in HPS. This description is often used to describe the appearance of stools in intussusception, which is a different gastrointestinal condition.
D. Projectile vomiting.
Hypertrophic pyloric stenosis is a condition in infants where the muscle at the outlet of the stomach (pylorus) becomes thickened and obstructs the passage of food from the stomach into the small intestine. Projectile vomiting is a characteristic symptom of HPS. The vomit is forceful and seems to shoot out of the infant's mouth, typically occurring after feeding.
Correct Answer is D
Explanation
A. Checking urine for glucose and protein is not directly related to the care of a child with a VP shunt. The focus is on monitoring the child for signs of complications related to the shunt.
B. Administering narcotics for pain control may be indicated if the child is in pain, but it is not the primary action and should be determined based on the child's pain assessment.
C. Testing cerebrospinal (CSF) fluid leakage for protein is not typically a nursing responsibility in the immediate postoperative period. Leakage of CSF should be reported to the healthcare provider, and diagnostic tests would be conducted by medical staff as needed.
D. Monitor for increased temperature.
Monitoring for an increased temperature is essential because postoperative fever could be an early sign of infection or complications related to the VP shunt. Infection and shunt malfunction are potential risks in the postoperative period.
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