A 50-year old male was brought toi the emergency department with a diagnosis of diabetes insipidus. The client had a posterior pituitary tumor. The nursing diagnosis most appropriate for this client is:

Correct Answer: C

Rationale: Diabetes insipidus is a condition characterized by excessive thirst and excretion of large amounts of dilute urine, resulting in fluid volume deficit. The posterior pituitary tumor in this case is likely causing decreased secretion of antidiuretic hormone (ADH), leading to the inability of the kidneys to concentrate urine and retain water. This imbalance results in the loss of fluid, leading to dehydration and electrolyte imbalances. Therefore, the most appropriate nursing diagnosis for this client is fluid volume deficit, as the priority is to address the dehydration and restore fluid balance to prevent further complications.

Correct Answer: A

Rationale: Syndrome of inappropriate antidiuretic hormone (SIADH) is characterized by excessive release of antidiuretic hormone (ADH), leading to water retention and dilutional hyponatremia. If a client with SIADH does not comply with the recommended treatment of diuretic therapy and fluid/sodium restriction, there will be continued water retention, resulting in further dilution of sodium levels in the blood (hyponatremia). Severe hyponatremia can lead to cerebral edema, which is a life-threatening complication associated with neurological symptoms such as headache, confusion, seizures, and potentially coma. Therefore, it is important for the client to follow the prescribed treatment to prevent the development of cerebral edema and other serious complications.

Correct Answer: B

Rationale: IV morphine is the most appropriate choice among the options provided for quickly reducing shortness of breath (SOB) in a crisis situation for a patient with end-stage respiratory disease. Morphine is commonly used in palliative care for symptom management in patients with severe respiratory distress. It acts as a respiratory depressant by reducing the perception of breathlessness, which can help alleviate the distressing symptoms of dyspnea. The rapid onset of action of IV morphine makes it an effective option for immediate relief in emergency situations for patients experiencing significant SOB due to end-stage respiratory disease. Oral cortisone, IM meperidine (Demerol), and IV propranolol (Inderal) are not primary choices for quickly reducing SOB in this context.

Correct Answer: B

Rationale: When communicating with an elderly client, it is important to use a low-pitched voice because high frequencies can be difficult for older individuals to hear. A low-pitched voice is easier for them to understand and can help enhance communication. Speaking clearly and directly in a calm manner with a lower pitch can make it easier for the elderly client to hear and comprehend what is being said. Additionally, it is important to speak at a moderate pace and volume to ensure effective communication with elderly clients.

Correct Answer: C

Rationale: When caring for a child with Cushing's syndrome, it is important to monitor weight each day and report any weight loss. Cushing's syndrome is characterized by a metabolic disorder that can lead to weight gain, particularly in the abdominal area. However, sudden weight loss in a child with Cushing's syndrome can be a sign of worsening condition or inadequate treatment. Therefore, monitoring weight regularly is crucial in managing the child's condition and adjusting the treatment plan accordingly.