A nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone. Which of the following findings should the nurse expect?

Excessive urinary output

Elevated sodium level

Bounding peripheral pulses

Hyperactive deep tendon reflexes

Answer and Explanation

The Correct Answer is C

A. Excessive urinary output: In syndrome of inappropriate antidiuretic hormone (SIADH), there is decreased urinary output, not excessive output. The body retains water due to increased antidiuretic hormone (ADH), leading to fluid retention.

B. Elevated sodium level: Due to excessive water retention and dilution of electrolytes, clients with SIADH typically experience hyponatremia (decreased sodium level), not an elevated sodium level. The retained water dilutes the body's sodium concentration.

C. Bounding peripheral pulses: Bounding peripheral pulses are expected in SIADH due to fluid overload, as the body retains excessive water. This leads to increased blood volume and can cause the peripheral pulses to feel strong or "bounding."

D. Hyperactive deep tendon reflexes: Hyperactive deep tendon reflexes are typically associated with conditions such as hypercalcemia or hyperthyroidism, not SIADH. SIADH is more likely to cause muscle weakness and fatigue due to hyponatremia.

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Correct Answer is C

Explanation

A. Gently squeeze the tubing to remove excess drainage: Squeezing the tubing is not recommended as it could cause injury or increase pressure within the system. The nurse should not manipulate the tubing in this way, as it does not address the continuous bubbling.
B. Raise the drainage system to the client's chest level: The drainage system should always be below the level of the client's chest to promote proper drainage. Raising the system to chest level could disrupt the drainage process and cause complications.
C. Clamp the tubing to check for air leaks: Continuous bubbling in the water seal chamber may indicate an air leak in the system. The nurse should clamp the tubing temporarily to isolate the source of the leak and check for any external leaks or loose connections.
D. Empty the collection chamber: The collection chamber should only be emptied when it is full. Continuous bubbling in the water seal chamber is more likely an indication of an air leak. The nurse should first assess for leaks before considering emptying the chamber.

A. Decreased urinary output B. Cool extremities C. Peripheral edema D. Crackles in the lung fields

Correct Answer is C

Explanation

A. Decreased urinary output: Decreased urinary output can occur in heart failure due to reduced kidney perfusion, but it is more commonly associated with left-sided heart failure as it leads to fluid congestion in the lungs and a decreased ability of the kidneys to function effectively.

B. Cool extremities: Cool extremities can occur in heart failure, but they are more commonly seen in left-sided heart failure due to poor circulation from the left ventricle. Right-sided heart failure primarily affects the systemic circulation.

C. Peripheral edema: Peripheral edema is a hallmark sign of right-sided heart failure. The right side of the heart is unable to pump blood efficiently to the lungs, causing blood to back up into the veins and resulting in fluid retention in the lower extremities and other parts of the body.

D. Crackles in the lung fields: Crackles in the lung fields are a characteristic finding in left-sided heart failure, as fluid backs up into the lungs. This is not typically a finding associated with right-sided heart failure, which affects the systemic circulation.

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A nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone. Which of the following findings should the nurse expect?

Nursing Test Bank

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