Which patient statement indicates to the nurse that further instruction is needed about chronic syndrome of inappropriate antidiuretic hormone (SIADH)?

"I need to shop for foods low in sodium and avoid adding salt to food."

"I need to limit my fluid intake."

"I should eat foods high in potassium because diuretics cause potassium loss."

"I should weigh myself daily and report sudden weight loss or gain."

Answer and Explanation

Correct Answer : B,C

Choice A reason: "I need to shop for foods low in sodium and avoid adding salt to food." This statement is correct and indicates appropriate understanding. Patients with SIADH need to manage their sodium intake carefully to avoid exacerbating hyponatremia.
Choice B reason: "I need to limit my fluid intake." This statement indicates a misunderstanding. Patients with SIADH should actually increase their fluid intake to help dilute the excess antidiuretic hormone and reduce hyponatremia. Limiting fluid intake can worsen the condition.
Choice C reason: "I should eat foods high in potassium because diuretics cause potassium loss." This statement is incorrect in the context of SIADH. While potassium intake is important for patients on diuretics, it is not directly related to SIADH management. The focus should be on managing fluid and sodium levels.
Choice D reason: "I should weigh myself daily and report sudden weight loss or gain." This statement is correct and indicates appropriate understanding. Regular weight monitoring is important for patients with SIADH to detect fluid imbalances early.

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Correct Answer is B

Explanation

Choice A reason: Quad coughing is a technique used to help patients with spinal cord injuries improve their coughing ability, but it does not directly prevent autonomic dysreflexia. While it is beneficial for respiratory health, it is not the primary intervention for preventing autonomic dysreflexia.
Choice B reason: Assisting to plan a prescribed bowel program is crucial in preventing autonomic dysreflexia. Bowel impaction is a common trigger for autonomic dysreflexia, and a regular bowel program helps to prevent constipation and ensure regular bowel movements, reducing the risk of this complication.
Choice C reason: Supporting the selection of a high-protein diet is important for overall health and nutrition, but it does not directly prevent autonomic dysreflexia. While proper nutrition is essential for patients with spinal cord injuries, it is not the primary intervention for preventing autonomic dysreflexia.

A. Assess for unilateral swelling, redness, and tenderness of either leg. B. Ask about any skin color changes that occur in response to cold. C. Palpate for the presence of dorsalis pedis and posterior tibial pulses. D. Look for the presence of tortuous veins bilaterally on the legs.

Correct Answer is C

Explanation

Choice A reason: Assessing for unilateral swelling, redness, and tenderness is important when evaluating for conditions such as deep vein thrombosis (DVT). However, this patient's symptoms of leg cramps and pain that subsides with rest are more indicative of peripheral artery disease (PAD) rather than DVT. Therefore, while this assessment is valuable in certain contexts, it is not the most relevant for this patient's symptoms.
Choice B reason: Asking about skin color changes that occur in response to cold can help identify conditions such as Raynaud's phenomenon, which causes extremities to change color in response to cold or stress. However, this patient's symptoms of intermittent leg cramps and pain with walking are more suggestive of PAD, making this question less relevant in this situation.
Choice C reason: Palpating for the presence of dorsalis pedis and posterior tibial pulses is the most appropriate focused assessment. This patient's symptoms of leg cramps and pain that resolve with rest suggest intermittent claudication, which is a hallmark of PAD. By palpating these pulses, the nurse can assess the adequacy of blood flow to the lower extremities, which is crucial in diagnosing PAD.
Choice D reason: Looking for the presence of tortuous veins bilaterally on the legs is important for identifying varicose veins, which are characterized by enlarged, twisted veins. While varicose veins can cause leg discomfort, they are not typically associated with the type of pain that subsides with rest. This patient's symptoms are more indicative of PAD, making this assessment less relevant.

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Which patient statement indicates to the nurse that further instruction is needed about chronic syndrome of inappropriate antidiuretic hormone (SIADH)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To prevent autonomic dysreflexia, which nursing action would the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level?

Correct Answer is B

Explanation

A patient at the clinic says, "I always walk after dinner, but lately my leg cramps and hurts after just a few minutes. The pain goes away after I stop walking, though." Which focused assessment would the nurse make?

Correct Answer is C

Explanation

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