W3 NR283 Exam 1
A patient with SIADH has a serum sodium level of 118 mEq/L. Which intervention is priority?
A. Encourage oral fluids
B. Administer hypertonic saline cautiously
C. Administer loop diuretics only
D. Restrict sodium intake
B – Administer hypertonic saline cautiously
,A client with increased intracranial pressure (ICP) begins to show widening pulse pressure, bradycardia,
and irregular respirations. What is the priority interpretation by the nurse?
A. Early sign of hypoxia
B. Compensated shock
C. Cushing’s triad indicating brain herniation
D. Normal response to pain
C – Classic Cushing’s triad, late sign of ICP → impending herniation (EMERGENCY).
,Which pathophysiological process explains cytotoxic cerebral edema?
A. Breakdown of blood-brain barrier
B. Increased capillary permeability
C. Cellular swelling due to sodium-potassium pump failure
D. Obstruction of venous outflow
C – Cellular swelling due to sodium-potassium pump failure
, A nurse notes a patient with hyperkalemia has muscle weakness. What is the underlying
mechanism?
A. Increased neuromuscular excitability
B. Decreased resting membrane potential stability
C. Enhanced sodium influx
D. Increased calcium binding
B – Decreased resting membrane potential stability
A patient with SIADH has a serum sodium level of 118 mEq/L. Which intervention is priority?
A. Encourage oral fluids
B. Administer hypertonic saline cautiously
C. Administer loop diuretics only
D. Restrict sodium intake
B – Administer hypertonic saline cautiously
,A client with increased intracranial pressure (ICP) begins to show widening pulse pressure, bradycardia,
and irregular respirations. What is the priority interpretation by the nurse?
A. Early sign of hypoxia
B. Compensated shock
C. Cushing’s triad indicating brain herniation
D. Normal response to pain
C – Classic Cushing’s triad, late sign of ICP → impending herniation (EMERGENCY).
,Which pathophysiological process explains cytotoxic cerebral edema?
A. Breakdown of blood-brain barrier
B. Increased capillary permeability
C. Cellular swelling due to sodium-potassium pump failure
D. Obstruction of venous outflow
C – Cellular swelling due to sodium-potassium pump failure
, A nurse notes a patient with hyperkalemia has muscle weakness. What is the underlying
mechanism?
A. Increased neuromuscular excitability
B. Decreased resting membrane potential stability
C. Enhanced sodium influx
D. Increased calcium binding
B – Decreased resting membrane potential stability
