A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will prescribe diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client does not comply with the recommended treatment, which complication may arise?

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: A

Rationale: Hypoglycemia is defined as a blood glucose level below 70mg/dl. When a client is experiencing hypoglycemia, it means their blood sugar is lower than the normal range and can lead to symptoms such as sweating, tremors, confusion, and even loss of consciousness. It is important for nurses to recognize and treat hypoglycemia promptly to prevent serious complications.

Correct Answer: A

Rationale: For J.E., who suffered head injuries in a motor vehicle accident, appropriate nursing interventions should focus on holistic care to prevent complications and promote recovery. Option A includes skin care and position changes every 2 hours (q2h) and as needed, which is crucial for preventing pressure injuries in the immobile patient. Maintaining alignment of extremities helps prevent muscle contractures. Respiratory exercises are essential for preventing atelectasis and improving lung function in patients at risk for pneumonia due to decreased mobility. These interventions address the immediate needs of the patient and aim to prevent further complications related to immobility and head injury. Options B, C, and D lack the comprehensive approach to care provided in option A, making it the most appropriate choice for J.E.

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: A

Rationale: An important consideration regarding TPN administration is ensuring the intravenous (IV) site is kept aseptic while infusing the solution. This is crucial to prevent the risk of infection, as TPN solutions are highly concentrated and can provide an ideal environment for the growth of microorganisms. Strict aseptic technique must be maintained during the entire process of TPN administration, from preparation to infusion, to minimize the risk of introducing pathogens into the patient's system. Failure to maintain aseptic technique can lead to serious complications such as bloodstream infections, which can be life-threatening for the patient.