The nurse is planning care for a client diagnosed with SIADH. Which of the following would be included in the plan of care? Select all that apply.
Administer 0.45% NS at 50 mL/hr
Obtain daily weight
Maintain seizure precautions
Administer 3% saline as ordered
Encourage fluid intake
Correct Answer : B,C,D
Choice A Reason:
Administering 0.45% NS (normal saline) at 50 mL/hr is not appropriate for a client with SIADH. This hypotonic solution can exacerbate the condition by increasing the water retention and further diluting the serum sodium levels, worsening hyponatremia. Instead, fluid restriction and hypertonic saline (such as 3% saline) are typically used to manage SIADH.
Choice B Reason:
Obtaining daily weight is crucial in managing SIADH. Daily weights help monitor fluid retention and detect any sudden changes in body weight, which can indicate worsening fluid overload or effective treatment. Accurate weight measurements are essential for assessing the client’s fluid balance and guiding treatment decisions.
Choice C Reason:
Maintaining seizure precautions is necessary for clients with SIADH because severe hyponatremia can lead to neurological symptoms, including seizures. Implementing seizure precautions helps ensure the client’s safety and allows for prompt intervention if a seizure occurs.
Choice D Reason:
Administering 3% saline as ordered is appropriate for treating severe hyponatremia in SIADH. Hypertonic saline helps increase serum sodium levels and reduce the risk of neurological complications. It must be administered carefully and under close monitoring to avoid rapid correction of sodium levels, which can lead to osmotic demyelination syndrome.
Choice E Reason:
Encouraging fluid intake is not appropriate for clients with SIADH. Fluid restriction is a key component of managing SIADH to prevent further dilution of serum sodium levels. Encouraging fluid intake would counteract this goal and worsen the client’s condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Assessing the client’s gag reflex before giving any food or water is crucial after a bronchoscopy. The procedure involves the use of local anesthesia to numb the throat, which can impair the gag reflex and increase the risk of aspiration. Ensuring that the gag reflex has returned before allowing the client to eat or drink helps prevent choking and aspiration, which are serious complications.
Choice B Reason:
Providing the client with ice chips instead of a drink of water is not the best initial action. While ice chips may seem like a safer option, they still pose a risk of aspiration if the gag reflex has not fully returned. The priority is to first assess the gag reflex to ensure the client can safely swallow.
Choice C Reason:
Contacting the primary healthcare provider and getting the appropriate orders is not necessary as the first action. The nurse can independently assess the gag reflex, which is a standard nursing practice after procedures involving throat anesthesia. If there are concerns after the assessment, then contacting the healthcare provider would be appropriate.
Choice D Reason:
Letting the client have a small sip to evaluate the ability to swallow is not safe without first assessing the gag reflex. This approach could lead to aspiration if the gag reflex has not returned. The initial step should always be to assess the gag reflex to ensure the client can safely swallow liquids.
Correct Answer is ["A","C","E"]
Explanation
Choice A Reason:
Weight loss.
Weight loss is a common symptom of hyperthyroidism. This condition speeds up the body’s metabolism, causing the body to burn calories more quickly than usual. Despite an increased appetite, individuals with hyperthyroidism often experience significant weight loss. This symptom is a direct result of the overproduction of thyroid hormones, which increases the metabolic rate.
Choice B Reason:
Intolerance to cold.
Intolerance to cold is not typically associated with hyperthyroidism; it is more commonly a symptom of hypothyroidism. Hyperthyroidism usually causes heat intolerance due to the increased metabolic rate, which raises the body’s temperature. Therefore, this choice is not relevant to hyperthyroidism.
Choice C Reason:
An elevated systolic blood pressure.
An elevated systolic blood pressure can be a symptom of hyperthyroidism. The increased levels of thyroid hormones can cause the heart to work harder, leading to higher blood pressure. This symptom is important to monitor as it can lead to further cardiovascular complications if left untreated.
Choice D Reason:
A heart rate of 90 bpm.
A heart rate of 90 bpm is within the normal range for adults and is not specifically indicative of hyperthyroidism. Hyperthyroidism typically causes a rapid or irregular heartbeat, often exceeding 100 bpm. Therefore, this choice does not accurately reflect a clinical manifestation of hyperthyroidism.
Choice E Reason:
Increased fatigability.
Increased fatigability is a common symptom of hyperthyroidism. Despite the increased metabolic rate, individuals with hyperthyroidism often feel tired and weak. This paradoxical symptom occurs because the body’s systems are overworked and cannot sustain the heightened activity levels, leading to fatigue.
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