A nurse is caring for a client who is exhibiting manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse report to the provider? (Select all that apply.)
Client has increased urine specific gravity.
Changes in the client's behavior.
Client is complaining of nausea.
Client is complaining of severe headache.
Client's urine output is only 50 cc/hr.
Correct Answer : A,B,C,D
A. Client has increased urine specific gravity: Increased urine specific gravity indicates concentrated urine, which is a hallmark of SIADH and should be reported as it reflects the excessive retention of water.
B. Changes in the client's behavior: Behavioral changes can be indicative of hyponatremia, a serious complication of SIADH, and should be reported immediately.
C. Client is complaining of nausea: Nausea is a symptom of hyponatremia, which is a common and dangerous consequence of SIADH that needs prompt attention.
D. Client is complaining of severe headache: A severe headache can also be a sign of hyponatremia and potential cerebral edema, both of which are critical conditions needing urgent intervention.
E. Client's urine output is only 50 cc/hr: While reduced urine output can be associated with SIADH, 50 cc/hr is not extremely low and might not be immediately alarming on its own. The other symptoms are more critical and should take precedence in reporting to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Poorly coordinated care and nosocomial infections are examples of errors: Poorly coordinated care, such as miscommunication between healthcare providers or lack of continuity in care, and nosocomial infections (infections acquired in the healthcare setting) are examples of errors that can compromise patient safety and contribute to adverse events.
B. Handoff errors are not causes of adverse events: Handoff errors, including miscommunication during transitions of care, are significant contributors to adverse events in healthcare settings. Improper handoffs can lead to misunderstandings, delays in treatment, and errors in medication administration.
C. Medication errors are intentional: Medication errors are unintended and can occur due to various factors, including human error, system failures, and communication breakdowns. They are not intentional acts.
D. As many as 10% of medication errors are preventable: Medication errors are often preventable with the implementation of safety measures such as barcode scanning, medication reconciliation, and standardized protocols. The percentage of preventable medication errors may vary depending on the healthcare setting and the effectiveness of safety initiatives.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"},"G":{"answers":"A"}}
Explanation
Client calm not agitated. Grimaces with movement.
No change: While the client is calm and not agitated, grimacing with movement indicates continued discomfort or pain, which remains unchanged.
Oral mucous membranes dry.
No change: Dry oral mucous membranes persist, suggesting ongoing dehydration or inadequate oral hydration.
Axillary temp 102 F (38.9 C), client shivering.
Declined: The axillary temperature has increased from 100.8 F (38.22 C) to 102 F (38.9 C), indicating a worsening of the client's fever. Shivering suggests the body's attempt to generate heat in response to the fever.
Productive cough.
No change: The client continues to have a productive cough, indicating ongoing respiratory congestion or infection.
Coarse rhonchi bilaterally. Crackles in bases.
Declined: The presence of coarse rhonchi bilaterally and crackles in the bases suggests worsening respiratory status, possibly indicating progression of underlying lung disease or development of complications such as pneumonia.
Respirations irregular with periods of apnea.
Improved: The client's respirations, previously irregular with periods of apnea, are now regular, indicating an improvement in respiratory function.
Client resting in recliner. RR 12, regular.
Improved: The client's respiratory rate has decreased from 18 to 12 breaths per minute, and respirations are now regular, suggesting improved respiratory status and possibly reduced distress.
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