A client sustained a head injury as a result of trauma. The health care provider has instituted seizure prophylactic measures. The nurse anticipates which specific measures being initiated for this client?

Aspiration precautions on day four of injury

Anticonvulsant medications on day two of injury

Intubation and ventilator support on day one of injury

Antiemetic medications on day three of injury

Answer and Explanation

The Correct Answer is B

Reasoning:

Choice A reason: Aspiration precautions are important in head injury to prevent pneumonia, particularly if consciousness is impaired, but they are not specific seizure prophylactic measures. Seizures require anticonvulsants to prevent neuronal hyperexcitability, making aspiration precautions a secondary concern unrelated to seizure prevention.

Choice B reason: Anticonvulsant medications, initiated early (e.g., day two), are standard for seizure prophylaxis in head injury. Trauma can cause cortical irritation, increasing seizure risk. Drugs like levetiracetam stabilize neuronal activity, preventing seizures, which could worsen brain injury or ICP, making this the primary measure.

Choice C reason: Intubation and ventilator support are used for severe head injuries with compromised airway or breathing but are not seizure prophylaxis. Seizures are managed with anticonvulsants, as mechanical ventilation does not address neuronal excitability, making this inappropriate for seizure prevention.

Choice D reason: Antiemetic medications manage nausea but are not seizure prophylactic measures. While vomiting may occur post-head injury, it does not prevent seizures, which result from cortical irritability. Anticonvulsants directly target seizure risk, making antiemetics irrelevant to this specific intervention goal.

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Correct Answer is D

Explanation

Reasoning:

Choice A reason: Diabetes insipidus causes hypernatremia due to excessive water loss from ADH deficiency, leading to polyuria and dehydration. This increases serum sodium concentration, not dilutional hyponatremia, which is characterized by low sodium due to water retention, making DI incorrect for this condition.

Choice B reason: Hypothyroidism affects metabolism through low thyroid hormone levels, causing symptoms like fatigue and weight gain. It does not directly cause dilutional hyponatremia, as it does not involve ADH or water retention. Sodium imbalances in hypothyroidism are rare and not dilutional in nature.

Choice C reason: Hyperthyroidism increases metabolism but does not typically cause dilutional hyponatremia. It may lead to dehydration from increased metabolic demand, but this does not involve excessive water retention or ADH dysfunction, which are necessary for dilutional hyponatremia to occur.

Choice D reason: SIADH causes dilutional hyponatremia due to excessive ADH, leading to water retention in the kidneys. This dilutes serum sodium, lowering its concentration. The increased fluid volume without corresponding sodium retention is the hallmark of SIADH, making it the correct endocrine disorder.

A. Confusion and diarrhea B. Hypertension and weight gain without edema C. Pulmonary congestion and muscle cramps D. Dyspnea and hypertension

Correct Answer is D

Explanation

Reasoning:

Choice A reason: Confusion may occur in SIADH due to hyponatremia-induced cerebral edema, but diarrhea is not a typical sign of fluid overload. Diarrhea causes fluid loss, which is opposite to the water retention seen in SIADH, making this combination less indicative of fluid overload compared to cardiovascular or respiratory signs.

Choice B reason: Hypertension may occur in SIADH due to fluid overload, but weight gain without edema is less specific. SIADH often causes subtle fluid retention without overt edema, but weight gain alone does not fully indicate fluid overload, as it lacks the respiratory or cardiovascular specificity of dyspnea and hypertension.

Choice C reason: Pulmonary congestion may indicate fluid overload in SIADH, as excess water can lead to pulmonary edema. However, muscle cramps are more related to hyponatremia than fluid overload itself. This combination is less precise than dyspnea and hypertension for identifying fluid overload in this context.

Choice D reason: Dyspnea and hypertension are key indicators of fluid overload in SIADH. Excessive ADH causes water retention, increasing blood volume, which raises blood pressure. Fluid accumulation in the lungs can cause dyspnea, reflecting pulmonary edema, a serious complication of fluid overload in SIADH, making this the most accurate finding.

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A client sustained a head injury as a result of trauma. The health care provider has instituted seizure prophylactic measures. The nurse anticipates which specific measures being initiated for this client?

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Naxlex Comprehensive Predictor Exams

Which endocrine disorder causes the client to have dilutional hyponatremia?

Correct Answer is D

Explanation

A nurse is caring for a client with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which finding would indicate that the client has developed fluid overload?

Correct Answer is D

Explanation

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters?

A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?

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