A nurse is caring for a client who has developed Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) from cancer. Which of the following nursing interventions should be included in the client's plan of care? (Select all that apply.)
Give the client a low sodium diet.
Monitor for serum electrolyte imbalances.
Obtain daily weights.
Educate the client on techniques to cope with thirst.
Increase IV fluids.
Correct Answer : A,B,C,D
A. Give the client a low sodium diet: SIADH causes retention of water and dilutional hyponatremia. Therefore, restricting sodium intake can help prevent further fluid retention and worsening of hyponatremia.
B. Monitor for serum electrolyte imbalances: SIADH can lead to electrolyte imbalances, particularly hyponatremia. Monitoring electrolyte levels, especially sodium, is essential for early detection and intervention.
C. Obtain daily weights: Monitoring daily weights is crucial for assessing fluid balance and detecting changes in hydration status, which is essential in clients with SIADH.
D. Educate the client on techniques to cope with thirst: Clients with SIADH often experience excessive thirst due to the body's inability to excrete excess water. Educating the client on strategies to manage thirst, such as chewing gum or sucking on ice chips, can help improve comfort.
E. Increase IV fluids: This option is incorrect because SIADH is characterized by water retention, so increasing IV fluids would exacerbate the condition and worsen hyponatremia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "My sense of smell is taking a long time to return.": This statement indicates a misunderstanding because, after a total laryngectomy, the sense of smell is significantly impaired or lost due to the inability to breathe through the nose. The client needs further teaching to understand that this change is likely permanent.
B. "Breathing through my stoma has diminished my sense of smell.": This statement is accurate as the stoma bypasses the nasal passages, reducing the sense of smell.
C. "I can't smell what I eat, but hope to enjoy eating in the future.": This shows an understanding that the sense of smell is impaired but expresses a positive outlook on enjoying food in other ways.
D. "I am happy to have a mild sense of taste despite no sense of smell.": This statement indicates an understanding of the sensory changes post-laryngectomy and reflects realistic expectations.
Correct Answer is A
Explanation
A. Tachypnea: Tachypnea, or rapid breathing, is a common symptom of pulmonary embolism. It occurs as the body attempts to compensate for decreased oxygenation and increased carbon dioxide levels resulting from impaired blood flow to the lungs. Tachypnea helps to improve gas exchange by increasing ventilation.
B. Wet cough: A wet or productive cough may occur in conditions such as pneumonia or chronic bronchitis but is not typically associated with pulmonary embolism. Pulmonary embolism is more commonly characterized by symptoms such as dyspnea, chest pain, and tachypnea.
C. Dull chest pain: Chest pain associated with pulmonary embolism is often sharp and pleuritic, meaning it worsens with deep breathing or coughing. It may be described as stabbing or like a "knife-like" sensation. Dull chest pain is not a typical finding in pulmonary embolism.
D. Episodes of apnea: While severe cases of pulmonary embolism can lead to respiratory failure and apnea, it is not a common presenting symptom. Most clients with pulmonary embolism will exhibit tachypnea as a compensatory mechanism to maintain adequate oxygenation.
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