A client with a closed head injury demonstrates signs of syndrome of inappropriate antidiuretic hormone (SIADH). Which additional finding should the nurse expect to obtain?

Weight gain of 2 pounds (0.91 kg) in one day.

Fremitus over the chest wall.

Serum sodium of 150 mEq/L (150 mmol/L).

Urine specific gravity of 1.004.

Answer and Explanation

The Correct Answer is A

Choice A reason: Weight gain of 2 pounds (0.91 kg) in one day is a sign of fluid retention, which occurs in SIADH due to excessive secretion of antidiuretic hormone (ADH). ADH causes the kidneys to reabsorb water and reduce urine output, leading to hyponatremia and hypervolemia.

Choice B reason: Fremitus over the chest wall is a sign of increased vibration or air movement in the lungs, which can indicate pneumonia, bronchitis, or pleural effusion. These are not related to SIADH, but may be complications of head injury or fluid overload.

Choice C reason: Serum sodium of 150 mEq/L (150 mmol/L) is a sign of hypernatremia, which is a high level of sodium in the blood. This is the opposite of what happens in SIADH, where sodium levels are low due to dilution by excess water.

Choice D reason: Urine specific gravity of 1.004 is a sign of diluted urine, which indicates low concentration of solutes in the urine. This is also the opposite of what happens in SIADH, where urine is concentrated and has a high specific gravity.

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Correct Answer is C

Explanation

Choice A reason: Lifting and clearing drainage from the chest tube is not necessary, as the water level fluctuations indicate that the chest tube is functioning properly and allowing air and fluid to escape from the pleural space.

Choice B reason: Inspecting the tube insertion site for leaking is not indicated, as there is no evidence of air leak in the water-seal chamber. An air leak would cause continuous or intermittent bubbling in the water-seal chamber.

Choice C reason: Continuing to monitor the drainage system is the best action for the nurse to implement, as the water level fluctuations are normal and expected in a water-seal drainage system. The water level should rise during inspiration and fall during expiration, reflecting the changes in intrathoracic pressure.

Choice D reason: Auscultating lungs for unequal breath sounds is not relevant, as it does not address the question of what to do with the water level fluctuations. Unequal breath sounds may indicate a pneumothorax or atelectasis, which are complications of chest trauma or chest tube insertion.

A. DenIes cramps, weakness, ornausea B. BP 116/68 mm Hg, HR 75 bpm C. Potasslum level 3.6 mEq/L3.6mmol/L) D. Verbalizes commitment to dialysisappointments E. Client states that she will need to resume her Lisinopril to control blood pressure F. Client is eager to add dark green vegetables and potatoes to her diet

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

a) Denies cramps, weakness, or nausea

This finding indicates that the actions taken were effective in relieving the patient's symptoms of fatigue, weakness, muscle cramps, and nausea. These symptoms may have been caused by electrolyte imbalances, dehydration, or infection related to her ESRD and missed dialysis sessions.

b) BP 116/68 mm Hg, HR 75 bpm

This finding indicates that the actions taken were effective in lowering the patient's blood pressure and heart rate. The patient had a history of HTN and CAD and presented with elevated BP and HR in the ED. The orders for EKG, cardiac monitor, chest X-ray, and echocardiogram may have helped to assess and manage her cardiac status. The patient may have also received antihypertensive medications or fluids as part of her treatment.

c) Potassium level 3.6 mEq/L (3.6 mmol/L)

This finding indicates that the actions taken were effective in normalizing the patient's potassium level. The patient had ESRD and missed dialysis sessions, which could have resulted in hyperkalemia or hypokalemia. The orders for basic metabolic panel and blood cultures may have helped to monitor and correct her electrolyte levels. The patient may have also received potassium supplements or binders as part of her treatment.

d) Verbalizes commitment to dialysis appointments

This finding indicates that the actions taken were effective in educating and motivating the patient to adhere to her dialysis schedule. The patient had ESRD and missed dialysis sessions, which could have worsened her condition and increased her risk of complications. The orders for CT scan of abdomen and echocardiogram may have helped to evaluate her renal function and cardiac function. The patient may have also received counseling or support from the health care team as part of her treatment.

e) Client states that she will need to resume her Lisinopril to control blood pressure

This finding indicates that the actions taken were ineffective in teaching the patient about her medication regimen. The patient had a history of HTN and CAD and was prescribed Lisinopril as an antihypertensive medication. However, Lisinopril is contraindicated in patients with ESRD as it can cause hyperkalemia or worsen renal function. The patient should be informed about the potential risks of taking Lisinopril and advised to consult with her nephrologist or primary care provider before resuming it.

f) Client is eager to add dark green vegetables and potatoes to her diet

This finding indicates that the actions taken were ineffective in educating the patient about her dietary restrictions. The patient had ESRD and required hemodialysis three times a week. She should follow a renal diet that limits the intake of potassium, phosphorus, sodium, and fluid. Dark green vegetables and potatoes are high in potassium and phosphorus and should be avoided or consumed in moderation by patients with ESRD. The patient should be provided with a list of foods that are suitable for her condition and referred to a dietitian for further guidance.

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A client with a closed head injury demonstrates signs of syndrome of inappropriate antidiuretic hormone (SIADH). Which additional finding should the nurse expect to obtain?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Exhibits For each assessment finding, explain whether the actions taken were effective or ineffective.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

A client with diabetes mellitus is admitted with an upper respiratory infection. Which changes in blood glucose management should the client expect?

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