A nurse cares for a patient with a possible diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH). The patient's serum sodium level is 114 mEq/L. What nursing action is appropriate?
Consult with the dietitian about increased dietary sodium.
Restrict the patient's fluid intake to between 500 to 1000 mL/day.
Instruct assistive personnel to measure intake and output.
Handle the patient gently by using turn sheets for repositioning.
The Correct Answer is B
Choice A rationale
A serum sodium level of 114 mEq/L indicates severe hyponatremia. The normal range for serum sodium is 135 to 145 mEq/L. SIADH is characterized by an excessive release of ADH, leading to water retention and dilutional hyponatremia. Increasing dietary sodium would not correct the underlying fluid imbalance and could potentially worsen the condition by causing further fluid shifts.
Choice B rationale
Fluid restriction is the primary treatment for SIADH and is crucial for managing dilutional hyponatremia. By restricting fluid intake to 500 to 1000 mL/day, the nurse helps to correct the water imbalance and increase serum sodium concentration. This action directly addresses the pathophysiology of SIADH, which is characterized by water retention.
Choice C rationale
While measuring intake and output is important for monitoring a patient with SIADH, it is a monitoring action, not a primary intervention to correct the sodium imbalance. The instruction to assistive personnel to perform this task is part of standard care but does not address the critical need for fluid restriction in a patient with severe hyponatremia.
Choice D rationale
Gentle handling is a precaution for patients with hyponatremia due to the risk of cerebral edema and seizure activity. However, it is not the most appropriate nursing action to address the underlying physiological problem of fluid retention and low serum sodium. Fluid restriction is the priority action to correct the fluid imbalance and prevent complications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Red blood cells are produced in the bone marrow, not the kidneys, and they do not produce erythropoietin. Erythropoietin is a hormone primarily produced by the kidneys in response to tissue hypoxia, which stimulates the bone marrow to produce red blood cells, thus increasing the oxygen-carrying capacity of the blood.
Choice B rationale
Anemia in renal insufficiency is not primarily related to vitamin D deficiency or bone density loss. While kidney disease can affect vitamin D activation and calcium-phosphate balance, the main cause of anemia in this context is the decreased production of erythropoietin by the failing kidneys.
Choice C rationale
The kidneys are the primary producers of erythropoietin in the body. When kidney function is compromised, this production is significantly reduced, leading to inadequate stimulation of the bone marrow. This results in decreased red blood cell production, causing the anemia commonly seen in patients with chronic renal insufficiency.
Correct Answer is C
Explanation
Choice A rationale
Chronically low blood pressure and dehydration are not characteristic of Cushing syndrome. Cushing syndrome is caused by prolonged exposure to high levels of cortisol. Cortisol, a glucocorticoid, increases sodium and water retention and potassium excretion. This fluid retention leads to increased blood volume and hypertension, not low blood pressure. The patient would typically have fluid overload, not dehydration.
Choice B rationale
Decreased axillary and pubic hair, known as sexual hair, is not a typical finding in Cushing syndrome. High cortisol levels can lead to excess androgen production, which in females may result in hirsutism, or excessive growth of male-pattern hair, including on the face, chest, and back. Decreased sexual hair is more commonly associated with conditions like Addison's disease or hypopituitarism, where there is a deficiency of adrenal hormones.
Choice C rationale
Purplish-red abdominal striae and a "moon face" are classic signs of Cushing syndrome. The high cortisol levels cause collagen breakdown, leading to thin, fragile skin that easily tears, forming these striae. The fat redistribution caused by cortisol excess leads to central obesity, a rounded or "moon" face, and a buffalo hump on the upper back. This combination of physical changes is pathognomonic for the condition.
Choice D rationale
Bulging of the eyes, or exophthalmos, and intolerance to heat are classic signs of hyperthyroidism, specifically Graves' disease. These symptoms are caused by an autoimmune process where antibodies stimulate the thyroid gland to produce excess thyroid hormones. They are not associated with Cushing syndrome, which is a disorder of the adrenal cortex and its regulation.
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