# A 64-year-old client with breast cancer metastatic to bone is admitted with 3 days of increasing confusion, nausea, thirst, frequent urination, and constipation. The client is oriented to person only, moves all extremities equally, and has no facial asymmetry. Mucous membranes are dry. Blood pressure is 104/62 mm Hg, heart rate 108/min, and temperature 36.8°C (98.2°F). Laboratory results: total calcium 13.8 mg/dL, albumin 2.8 g/dL (corrected calcium 14.8 mg/dL), sodium 138 mEq/L, potassium 4.1 mEq/L, phosphorus 2.6 mg/dL, uric acid 5.8 mg/dL, and creatinine 1.3 mg/dL (baseline 0.9 mg/dL). The ECG shows sinus tachycardia with a shortened QT interval. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617371&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

A 64-year-old client with breast cancer metastatic to bone is admitted with 3 days of increasing confusion, nausea, thirst, frequent urination, and constipation. The client is oriented to person only, moves all extremities equally, and has no facial asymmetry. Mucous membranes are dry. Blood pressure is 104/62 mm Hg, heart rate 108/min, and temperature 36.8°C (98.2°F). Laboratory results: total calcium 13.8 mg/dL, albumin 2.8 g/dL (corrected calcium 14.8 mg/dL), sodium 138 mEq/L, potassium 4.1 mEq/L, phosphorus 2.6 mg/dL, uric acid 5.8 mg/dL, and creatinine 1.3 mg/dL (baseline 0.9 mg/dL). The ECG shows sinus tachycardia with a shortened QT interval. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Hypercalcemia of malignancy
Tumor lysis syndrome
Syndrome of inappropriate antidiuretic hormone
Brain metastasis with cerebral edema

Actions to take

Select 2
Administer the prescribed IV furosemide before any fluids
Infuse the prescribed 0.9% sodium chloride bolus
Administer the prescribed IV rasburicase
Restrict oral and IV fluid intake to 1 L per day
Administer the prescribed IV zoledronic acid

Parameters to monitor

Select 2
Serum uric acid
Serum calcium corrected for albumin
Urine output per hour
Serum sodium
Pupil response and focal motor strength

## Explanation

A corrected calcium of 14.8 mg/dL with confusion, polyuria, dehydration, and a short QT in a client with bone metastases is severe hypercalcemia of malignancy. Initial treatment is isotonic saline to restore volume and calcium excretion, plus an IV antiresorptive such as zoledronic acid for sustained control. Corrected calcium and hourly urine output show response; loop diuretics are no longer given before volume repletion.

## In-depth explanation

Quick answer
Hypercalcemia of malignancy. Actions: infuse the prescribed 0.9% sodium chloride bolus; administer the prescribed IV zoledronic acid. Monitor: serum calcium corrected for albumin, and hourly urine output.

Why this is correct
Calcium must be corrected for low albumin: 13.8 + 0.8 x (4.0 - 2.8) = about 14.8 mg/dL, a severe level. High calcium causes nephrogenic diabetes insipidus, so the client is volume depleted, which lowers renal calcium clearance and worsens the cycle. Isotonic saline breaks the cycle quickly, and a bisphosphonate stops osteoclast bone resorption, taking 2 to 4 days for full effect. The Endocrine Society guideline recommends an IV bisphosphonate or denosumab for hypercalcemia of malignancy.

Easy analogy or mental picture
Picture a bathtub overflowing with calcium: saline pulls the drain open (renal excretion) while the bisphosphonate turns off the tap (bone resorption). You watch the water level (calcium) and the drain flow (urine output).

Memory hook
Stones, bones, groans, moans, and a short QT: fill the tank, then block the bone.

NCLEX decision rule
When an electrolyte emergency is driven by volume depletion, restore volume first; add drugs that act on the source next, and monitor the electrolyte and the output that clears it.

Why the other choices are wrong
Tumor lysis syndrome also occurs in cancer and can cause confusion and kidney injury, but it causes low calcium with high potassium, phosphorus, and uric acid; these are normal here, so rasburicase and a uric acid trend target the wrong problem. SIADH causes confusion but requires hyponatremia; sodium is 138 mEq/L, so fluid restriction would worsen dehydration and serum sodium is not the key trend. Brain metastasis is tempting in metastatic cancer, but the exam is nonfocal and calcium explains the findings, so pupil and motor checks are less specific. Furosemide before volume repletion is an outdated practice that worsens hypovolemia.

References
1Endocrine Society Clinical Practice Guideline: Treatment of Hypercalcemia of Malignancy in AdultsIV bisphosphonate or denosumab for hypercalcemia of malignancy, with initial IV hydration.

## Clinical scenario

Scenario
A client with bone metastases has confusion, polyuria, dehydration, constipation, a corrected calcium of 14.8 mg/dL, a shortened QT interval, and a creatinine rise from 0.9 to 1.3 mg/dL.

## Key concepts

- **Corrected calcium** — Total calcium adjusted for low albumin, about 0.8 mg/dL added for each 1 g/dL albumin below 4.0.
- **Antiresorptive therapy** — Drugs such as bisphosphonates or denosumab that reduce osteoclast bone breakdown.
- **Nephrogenic diabetes insipidus** — Loss of renal concentrating ability, caused here by hypercalcemia, leading to polyuria and dehydration.

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