ATI flashcards set 5

Turner's sign

- This is an indication of acute pancreatitis, bluish discoloration of the flanks (between ribs & pelvis).

Urine Osmolality

Normal is 500 to 1200 mOsm/kg.

Normal Sodium Level

135-145 mEq/L

Which of the following is the best indicator for determining whether a client with Addison's disease is receiving the correct amount of glucocorticoid replacement?

Daily weight. Explanation: Measuring daily weight is a reliable, objective way to monitor fluid balance.

Murphy's sign

Hook your thumb or the fingers of your right hand under the costal margin at the point where the lateral border of the rectus muscle intersects witht he costal margin. Ask the patient to take a deep breath. A sudden stop in inspiratory effort constitutes a positive sign. Test is for Acute Cholecystitis (Galbladder)

A nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse expects to find:

deposits of adipose tissue in the trunk and dorsocervical area.

decerebrate rigidity

A characteristic of a corticospinal lesion at the level of the brainstem that results in extension of the trunk and all extremities.

McBurney's point

A point of reference located in the RLQ that may indicate that a patient has appendicitis is known as?

Syndrome of Inappropriate Antidiuretic Hormone

- Failure of negative feedback system that regulates ADH. Too much fluid retained - Causes water intoxication. Can be cause by malignant tumors secreting ADH like substance. Urine osmolality>1200, specific gravity > 1.035. Serum osmolality <275.

Adrenal crisis

- acute adrenal insufficiency, has a rapid onset. - it is a medical emergency. - if it is not quickly diagnosed and properly treated, the prognosis is poor.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?

Serum sodium level of 124 mEq/L

Serum Osmolality

270 to 300 mOsm/L - Measures the concentration of particles in a solution

Addison's disease

- adrenocorticol insufficiency. It is caused by damage or dysfunction of the adrenal cortex, which produces: mineralcorticoids (aldosterone), glucocorticodes (cortisol), and sex hormones (androgens and estrogens) - decreased aldosterone and cortisol R/F Primary - idiopathic autoimmune dysfunction (majority of cases) - TB - histoplasmosis - adrenalectomy - cancer Secondary - steroid withdrawel - hypophysectomy - pituitary neoplasm acute adrenocortical insuff. - Sepsis, trauma, stress, adrenal hemorrhage, steroid withdrawal Assessment - S/S develop slowly - hyperpigmentation - weakness, fatigue - N/V - dizziness with orthostatic hypotension - severe hypotension - dehydration - hyponatremia - hyperkalemia - hypoglycemia - hypercalcemia Diagnostic Tests - Serum Electrolytes (increased KCL, Decreased Na+, increased Ca) - Increased BUN/Creatinine - decreased serum coritsol - ACTH stimulation tests - cortisol levels fail to rise. - ECG, X-ray, CT - to look for tumors Collaboration - Monitor fluids i&o, - monitor for hyponatremia - give ivf - monitor for dehydration - monitor and treat hyperkalemia - give kayexalate, insulin, glucose, and sodium bicarb if prescribed. - monitor and treat hypoglycemia - neuro checks, bsg checks, give food/glucose if needed - maintain safe environment, assist with ambulation, siderails,fall precautions Meds - Hydrocortisone, Prednisone, Cortisone - monitor weight, bp, and electrolytes - increase dosage during stress - taper if discontinuing - give with food

A client who recently underwent cranial surgery develops syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following symptoms should the nurse anticipate? A. Edema and weight gain. B. Excessive urinary output. C. Fluid loss and dehydration. D. Low urine specific gravity

A Syndrome of inappropriate antidiuretic hormone (SIADH) results in an abnormally high release of antidiuretic hormone, which causes water retention as serum sodium levels fall, leading to edema and weight gain. Because of fluid retention, urine output is low. Fluid is restricted to prevent fluid overload rather than replaced. As the urine becomes more concentrated, the specific gravity increases. Other symptoms include nausea, vomiting, seizures, altered mentation, and coma. SIADH is most common with diseases of the hypothalamus but can also occur with heart failure, Guillain-Barré syndrome, meningitis, encephalitis, head trauma, or brain tumors. It may also be triggered by medications.

A client with Addison's disease is admitted to the medical unit. The client has fluid and electrolyte loss due to inadequate fluid intake and to fluid loss secondary to inadequate adrenal hormone secretion. As the client's oral intake increases, which of the following fluids would be most appropriate?

Bouillon and juice. Explanation: Electrolyte imbalances associated with Addison's disease include hypoglycemia, hyponatremia, and hyperkalemia. Salted bouillon and fruit juices provide glucose and sodium

The client with Addison's disease should anticipate the need for increased glucocorticoid supplementation in which of the following situations?

Having oral surgery.

Bone resorption is a possible complication of Cushing's disease. Which of the following interventions should the nurse recommend to help the client prevent this complication?

Maintain a regular program of weight-bearing exercise.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Laboratory results reveal serum sodium level 130 mEq/L and urine specific gravity 1.030. Which nursing intervention helps prevent complications associated with SIADH?

Restricting fluids to 800 ml/day Explanation: Excessive release of antidiuretic hormone (ADH) disturbs fluid and electrolyte balance in SIADH.

A client is admitted to the health care facility for evaluation for Addison's disease. Which laboratory test result best supports a diagnosis of Addison's disease?

Serum potassium level of 5.8 mEq/L Addison's disease decreases the production of aldosterone, cortisol, and androgen, causing urinary sodium and fluid losses, an increased serum potassium level, and hypoglycemia.

A client with Cushing's disease tells the nurse that the physician said the morning serum cortisol level was within normal limits. The client asks, "How can that be? I'm not imagining all these symptoms!" The nurse's response will be based on which of the following concepts?

The excessive cortisol levels seen in Cushing's disease commonly result from loss of the normal diurnal secretion pattern.