The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who was admitted to the intensive care unit (ICU) yesterday. Which intervention is most important for the nurse to include in the client's plan of care (POC)?
Report signs of increasing irritability.
Administer a PRN antiemetic.
Monitor serum sodium levels.
Assess for peripheral edema daily.
The Correct Answer is C
Rationale:
A. Report signs of increasing irritability: Changes in mental status, such as irritability, can indicate worsening hyponatremia. While important to monitor, this is a symptom rather than a direct measure of the client’s condition.
B. Administer a PRN antiemetic: Anti-nausea medication may relieve symptoms but does not address the underlying electrolyte imbalance or prevent complications of SIADH. It is supportive care, not a priority intervention.
C. Monitor serum sodium levels: Hyponatremia is the hallmark of SIADH and can lead to seizures, coma, or death if severe. Frequent monitoring of serum sodium is critical to guide fluid restriction, hypertonic saline administration, and other interventions, making it the most important nursing action.
D. Assess for peripheral edema daily: SIADH typically causes water retention without significant peripheral edema because fluid accumulates intracellularly rather than in the interstitial space. Monitoring edema is less critical than tracking serum sodium.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Bounding erratic pulse: A bounding pulse indicates strong cardiac output, which is inconsistent with ventricular fibrillation, where the ventricles fail to pump effectively.
B. No palpable pulse: Ventricular fibrillation causes chaotic ventricular contractions, preventing effective cardiac output. As a result, the client will have no palpable pulse and will be unresponsive, making this the expected and urgent finding.
C. Thready irregular pulse: A thready, weak, or irregular pulse may occur in severe hypotension or arrhythmias, but VF typically produces no pulse at all due to lack of coordinated ventricular contraction.
D. Regularly irregular pulse: A regularly irregular pulse suggests atrial arrhythmias or other conduction abnormalities but does not correspond to the chaotic, ineffective contractions seen in VF.
Correct Answer is C
Explanation
Rationale:
A. Report signs of increasing irritability: Changes in mental status, such as irritability, can indicate worsening hyponatremia. While important to monitor, this is a symptom rather than a direct measure of the client’s condition.
B. Administer a PRN antiemetic: Anti-nausea medication may relieve symptoms but does not address the underlying electrolyte imbalance or prevent complications of SIADH. It is supportive care, not a priority intervention.
C. Monitor serum sodium levels: Hyponatremia is the hallmark of SIADH and can lead to seizures, coma, or death if severe. Frequent monitoring of serum sodium is critical to guide fluid restriction, hypertonic saline administration, and other interventions, making it the most important nursing action.
D. Assess for peripheral edema daily: SIADH typically causes water retention without significant peripheral edema because fluid accumulates intracellularly rather than in the interstitial space. Monitoring edema is less critical than tracking serum sodium.
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