Question set B: matrix, bowtie, and drop-down
An empty bowtie scaffold, two left cells angling into a plum-filled center cell and two right cells angling outward, headed ACTIONS TO TAKE, CONDITION, PARAMETERS TO MONITOR, over a bordered option bank strip.
9 · MATRIX. For each finding, mark the one column that applies.
| FINDING | SIADH | DIABETES INSIPIDUS | NEITHER |
|---|---|---|---|
| a. Scant, dark urine with a high specific gravity | |||
| b. Weight gain of 4 pounds in two days with no dependent edema | |||
| c. Intense thirst with pale, copious urine | |||
| d. Serum sodium falling on serial draws | |||
| e. Urine output greater than 300 mL per hour for three consecutive hours, nearly colorless | |||
| f. Muddy brown casts on urine sediment |
10 · BOWTIE. A 44-year-old with a long history of untreated hyperthyroidism is two hours post-thyroidectomy. Temperature 104.2 degrees Fahrenheit, pulse 156 and irregular, blood pressure 168/62 mm Hg. She is agitated, tremulous, and does not recognize her daughter. Place one condition in the center, two actions on the left, and two parameters to monitor on the right.
Option bank: thyroid storm · myxedema coma · adrenal crisis · postoperative hemorrhage · apply cooling measures without salicylates · apply a warming blanket · place in a quiet, low-stimulation room with continuous cardiac monitoring · encourage ambulation · restrict all oral fluids · core temperature · cardiac rate and rhythm · deep tendon reflexes · urine specific gravity
11 · DROP-DOWN. Complete the sentence. In acute kidney injury, hyperkalemia is the leading danger during the [A] phase, while the phase in which the nurse instead watches for hypovolemia and potassium loss is the [B] phase. A: onset / oliguric / diuretic / recovery. B: onset / oliguric / diuretic / recovery.
12 · DROP-DOWN. Complete the sentence. Before a patient admitted with an acute ischemic stroke receives anything by mouth, the nurse must first complete a [A], because [B] places the patient at risk for aspiration pneumonia. A: swallow screen / gag reflex check / full cranial nerve examination / speech-language evaluation. B: aphasia / dysphagia / facial droop / neglect.
RATIONALES
Item 9 — Answer: a SIADH, b SIADH, c DI, d SIADH, e DI, f Neither Why a is SIADH: retained water leaves urine scant and concentrated. Why b is SIADH: retained water distributes into cells, so weight rises without edema. Why c is DI: water pours out, so the patient is thirsty and the urine is dilute. Why d is SIADH: retained water dilutes the serum sodium. Why e is DI: massive dilute output is the defining finding. Why f is neither: muddy brown casts belong to intrarenal acute kidney injury → BOOK 10 · P8. The rule: read the urine first, then predict the sodium in the opposite direction.
Item 10 — Answer: center thyroid storm; actions cooling without salicylates and quiet room with cardiac monitoring; parameters core temperature and cardiac rate and rhythm Why thyroid storm is right: surgery on an undertreated hyperthyroid gland, plus fever, tachyarrhythmia, and agitated delirium. Why myxedema coma is wrong: it is the mirror image, with hypothermia and bradycardia. Why adrenal crisis is wrong: it presents with fluid-unresponsive hypotension, not hypertension with fever. Why postoperative hemorrhage is wrong: it would show neck swelling and hypotension. Why cooling without salicylates is right: salicylates displace thyroid hormone from binding proteins and raise the free level. Why the quiet room with monitoring is right: it reduces stimulation while the lethal arrhythmia risk is watched. Why a warming blanket is wrong: it treats the opposite crisis. Why ambulation is wrong: it adds metabolic demand to a patient already in a hypermetabolic storm. Why restricting all oral fluids is wrong: fever and hypermetabolism increase fluid need. Why deep tendon reflexes and urine specific gravity are wrong: neither tracks the two things that kill here. The rule: the bowtie center is the diagnosis, not the intervention.
Item 11 — Answer: A oliguric, B diuretic Why oliguric is right for A: urine output falls, potassium is not excreted, and it accumulates. Why diuretic is right for B: output surges and the patient loses volume and potassium. Why onset is wrong: the injury is developing and neither danger has arrived. Why recovery is wrong: function is returning over months. The rule: the danger flips direction when the urine does.
Item 12 — Answer: A swallow screen, B dysphagia Why swallow screen is right for A: it is the specific bedside screen validated to precede oral intake after stroke. Why gag reflex check is wrong: an intact gag does not prove a safe swallow. Why a full cranial nerve examination is wrong: it is broader and slower and still does not clear the patient to swallow. Why a speech-language evaluation is wrong: it follows a failed screen rather than replacing it. Why dysphagia is right for B: impaired swallowing is the mechanism of aspiration. Why aphasia, facial droop, and neglect are wrong: each is a real stroke deficit, but none of them is the swallowing failure that causes aspiration. The rule: screen before the first sip, every time.
Margin notethe bowtie asks for the diagnosis in the middle, not the intervention. Format mechanics are → BOOK 02 · P8.
Takeawaynext-generation formats change the shape of the answer, not the reasoning; the cue still comes first.