Endocrine Question #13

Question

The nurse is caring for a client who just came to the emergency department with a diagnosis of acute syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which nursing diagnosis is most important to use prior to treatment?

Answers

  1. Risk for thromboembolism
    • Rationale:
  2. Risk for infection
    • Rationale:
  3. Activity intolerance
    • Rationale:
  4. Fluid volume excess
    • Rationale:

Overview

Explanation

Fluid overload is a sign and symptom of SIADH and presenting problem will be fluid volume excess. Selection A is incorrect. While circulation and fluid stasis related to fluid overload may leave the client at risk for venous thrombosis, it is not the most important presenting problem. Selection B is incorrect. While risk for infection will be important it is not priority since the client’s condition is acute with SIADH and the presenting problem will be fluid overload. Selection C is incorrect since activity intolerance is not the most important problem during the acute stage of SIADH. SIADH presents with fluid overload, hypertension, tachycardia, hyponatremia, possible seizures, and low urine output. The condition results from high levels of ADH, which plays a role in retention of fluid in the body.

Learning Outcomes

Test Taking Tip

Video Rationale