A nurse is caring for a client with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which finding would indicate that the client has developed fluid overload?
Confusion and diarrhea
Hypertension and weight gain without edema
Pulmonary congestion and muscle cramps
Dyspnea and hypertension
The Correct Answer is D
Reasoning:
Choice A reason: Confusion may occur in SIADH due to hyponatremia-induced cerebral edema, but diarrhea is not a typical sign of fluid overload. Diarrhea causes fluid loss, which is opposite to the water retention seen in SIADH, making this combination less indicative of fluid overload compared to cardiovascular or respiratory signs.
Choice B reason: Hypertension may occur in SIADH due to fluid overload, but weight gain without edema is less specific. SIADH often causes subtle fluid retention without overt edema, but weight gain alone does not fully indicate fluid overload, as it lacks the respiratory or cardiovascular specificity of dyspnea and hypertension.
Choice C reason: Pulmonary congestion may indicate fluid overload in SIADH, as excess water can lead to pulmonary edema. However, muscle cramps are more related to hyponatremia than fluid overload itself. This combination is less precise than dyspnea and hypertension for identifying fluid overload in this context.
Choice D reason: Dyspnea and hypertension are key indicators of fluid overload in SIADH. Excessive ADH causes water retention, increasing blood volume, which raises blood pressure. Fluid accumulation in the lungs can cause dyspnea, reflecting pulmonary edema, a serious complication of fluid overload in SIADH, making this the most accurate finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Reasoning:
Choice A reason: Excessive thirst, or polydipsia, is a hallmark of diabetes insipidus. ADH deficiency leads to excessive water loss through dilute urine, causing dehydration. This triggers the thirst mechanism to compensate for fluid loss, prompting increased water intake to maintain hydration, a key clinical feature of this condition.
Choice B reason: Low urine output, or oliguria, is not associated with diabetes insipidus. This condition causes polyuria due to impaired water reabsorption from ADH deficiency, leading to large volumes of dilute urine. Low urine output is more typical of conditions like acute kidney injury or SIADH.
Choice C reason: Weight gain is not a feature of diabetes insipidus. The condition leads to water loss and dehydration, often causing weight loss due to reduced fluid volume. Weight gain might occur in conditions like SIADH, where water retention dilutes sodium and increases body fluid content.
Choice D reason: Excessive activities are not a clinical manifestation of diabetes insipidus. This condition primarily affects fluid balance, causing polyuria and polydipsia. Increased activity levels are not linked to ADH deficiency, and patients may experience fatigue due to dehydration, not heightened physical activity.
Correct Answer is A
Explanation
Reasoning:
Choice A reason: Risk for injury is the priority for a client with left-sided hemiparesis post-stroke. Weakness on one side impairs mobility and balance, increasing fall risk. Home environment assessment ensures removal of hazards like rugs or clutter, promoting safety and preventing injuries, critical for stroke recovery.
Choice B reason: Ineffective coping may occur post-stroke due to emotional or functional challenges, but it is not the primary focus during home environment assessment. Physical safety from falls due to hemiparesis is more immediate, as coping issues are addressed through counseling, not environmental modifications.
Choice C reason: Noncompliance with treatment may affect stroke recovery but is not directly addressed by home environment assessment. Ensuring a safe environment to prevent falls due to hemiparesis takes precedence, as physical safety is critical before addressing behavioral or adherence issues in discharge planning.
Choice D reason: Diarrhea is unrelated to hemiparesis or home environment assessment post-stroke. It may occur from medications or other causes but does not pose an immediate risk like falls. The focus is on preventing injuries due to mobility issues, not gastrointestinal symptoms, in this context.
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