A client is brought to the ED by family after falling off the roof. The care team suspects an epidural hematoma, prompting the nurse to anticipate which priority intervention?

Reasoning:

Choice A reason: Encouraging independence without assistance in an impulsive client post-hemorrhagic stroke increases fall risk. Their lack of insight into limitations heightens injury potential. A bed alarm is safer, as it alerts staff to assist, preventing falls due to unrecognized motor or cognitive deficits.

Choice B reason: Ordering restraints like vests or wrist restraints is not the first choice, as they restrict autonomy and may increase agitation in an impulsive client. Non-invasive measures like bed alarms are preferred to prevent injury while preserving dignity and promoting safe mobility post-stroke.

Choice C reason: Encouraging family to reprimand the client for not seeking help may increase emotional distress and does not prevent injury. It fails to address impulsive behavior directly. A bed alarm proactively alerts staff to assist, reducing fall risk more effectively than behavioral reprimands.

Choice D reason: Installing a bed alarm is the priority to prevent injury in an impulsive client post-hemorrhagic stroke. It alerts staff when the client attempts to move unassisted, compensating for their lack of insight into limitations, reducing fall risk, and ensuring timely assistance for safe mobility.

Reasoning:

Choice A reason: Dilute urine is not expected in SIADH, as excessive ADH promotes water reabsorption in the kidneys’ collecting ducts, leading to concentrated urine with high osmolality. Dilute urine is characteristic of diabetes insipidus, where ADH deficiency causes excessive water loss, producing large volumes of dilute urine.

Choice B reason: Hypernatremia is not a manifestation of SIADH. Excessive ADH causes water retention, diluting serum sodium and leading to hyponatremia. Hypernatremia occurs in conditions like diabetes insipidus, where water loss concentrates sodium, opposite to the fluid overload seen in SIADH.

Choice C reason: Increased serum osmolality is not typical in SIADH. Water retention due to excessive ADH dilutes serum sodium and osmol Jon the same paragraph, and the correct answer with detailed scientific rationales for each choice. The text will be in regular font, with no bold, and each question will be clearly numbered with two lines skipped after the number and one line after the question. I will avoid in-text citations and ensure scientific explanations are detailed and at least 58 words long.

Choice D reason: Concentrated urine is a hallmark of SIADH due to excessive ADH, which promotes water reabsorption in the renal collecting ducts, reducing urine volume and increasing its osmolality. This contrasts with diabetes insipidus, where dilute urine is produced, making concentrated urine a key diagnostic feature of SIADH.