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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Align the transducer to the level of the client's radial artery: The transducer should be aligned to the level of the phlebostatic axis at the fourth intercostal space, mid-axillary line, not the radial artery.
B. Maintain the pressure bag at 300 mm Hg of pressure: The pressure bag should be maintained at 300 mm Hg to ensure that the pressure within the system is higher than the client’s arterial pressure. This helps to prevent blood from flowing back into the tubing.
C. Infuse 0.9% sodium chloride at 150 mL/hr: Infusion through an arterial line is not recommended for fluids like 0.9% sodium chloride, as arterial lines are for pressure monitoring and blood sampling. Fluids should be infused through a separate IV line.
D. Have the client bear down when checking their blood pressure: The client should not bear down when checking blood pressure with an arterial line. Bearing down could artificially raise intra-abdominal pressure and affect the reading.
Correct Answer is C
Explanation
A. Nosebleed: A nosebleed is not typically associated with dialysis disequilibrium. It may be related to other factors like dry air or blood pressure changes, but it is not a classic symptom of dialysis disequilibrium.
B. Malaise: Malaise can occur after hemodialysis due to various reasons, such as fluid shifts, but it is not a specific indicator of dialysis disequilibrium.
C. Headache: Headache is a common symptom of dialysis disequilibrium, which occurs due to rapid changes in fluid and electrolyte balance during hemodialysis. This can lead to cerebral edema, which manifests as a headache.
D. Elevated temperature: An elevated temperature is not a typical sign of dialysis disequilibrium. It could indicate an infection or other issues related to dialysis, but it is not directly related to disequilibrium.
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