A nurse is caring for a client with diabetes insipidus (DI). Which data warrants the most immediate intervention by the nurse?
Reference Range: Sodium 136 to 145 mEq/L (136 to 145 mmol/L)
Polyuria and excessive thirst
Serum sodium of 185 mEq/L (185 mmol/L)
Apical heart rate of 110 beats per minute
Dry skin with inelastic turgor
The Correct Answer is B
Choice A reason: Polyuria and excessive thirst are classic symptoms of diabetes insipidus and indicate the body's inability to retain water due to a lack of antidiuretic hormone (ADH). While these symptoms need to be managed, they are not immediately life-threatening compared to severe hypernatremia.
Choice B reason: A serum sodium level of 185 mEq/L (185 mmol/L) indicates severe hypernatremia, which is an immediate medical emergency. Severe hypernatremia can lead to neurological symptoms such as confusion, seizures, and even coma due to the osmotic shift of water out of brain cells. Immediate intervention is required to correct the sodium imbalance and prevent serious complications.
Choice C reason: An apical heart rate of 110 beats per minute is indicative of tachycardia, which can be associated with dehydration and the body's response to maintain cardiac output. While it is a concern, it does not take precedence over the need to address severe hypernatremia.
Choice D reason: Dry skin with inelastic turgor is a sign of dehydration, which is a common issue in diabetes insipidus due to excessive fluid loss. While this requires attention, it is not as immediately critical as addressing severe hypernatremia, which poses a direct and urgent threat to the client's neurological and overall health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Central line insertion is not the appropriate intervention for managing stridor in a postoperative parathyroidectomy patient. Stridor indicates airway obstruction, which requires immediate airway management, not central venous access. Inserting a central line would not address the underlying issue of compromised airway patency, and it would delay necessary interventions to secure the airway.
Choice B reason: Nasogastric tube (NGT) insertion is not the correct intervention for stridor. NGT insertion is typically used for gastrointestinal decompression or feeding, not for managing airway obstruction. In the context of a client experiencing stridor, the priority is to ensure a patent airway, not to manage gastrointestinal issues. NGT insertion could potentially exacerbate airway compromise in a client with stridor.
Choice C reason: Tracheostomy placement is the correct intervention for managing stridor in a postoperative parathyroidectomy patient. Stridor indicates a potential airway obstruction, which can be life-threatening. A tracheostomy provides a secure airway and ensures adequate ventilation. This procedure is particularly important in cases where upper airway obstruction is suspected, such as swelling or hematoma formation following neck surgery.
Choice D reason: Pacemaker placement is not relevant to managing stridor. Pacemakers are used for cardiac rhythm management and do not address airway obstruction. The immediate concern for a client with stridor is ensuring a patent airway, and pacemaker placement would not resolve the airway compromise.
Correct Answer is A
Explanation
Choice A reason: A complete blood count (CBC) is the most relevant laboratory value to review for a client with iron deficiency anemia who reports increased fatigue. The CBC will provide important information about the levels of red blood cells, hemoglobin, and hematocrit, which are directly affected by iron deficiency. Monitoring these values will help determine if the client’s anemia is worsening or if the iron supplements are not effectively improving the blood count.
Choice B reason: The platelet count is part of a CBC but is not directly related to the symptoms of fatigue in iron deficiency anemia. While platelet levels are important for assessing clotting function, they do not provide the necessary information about red blood cell levels or hemoglobin concentration that are central to diagnosing and managing anemia.
Choice C reason: Serum electrolytes are important to monitor for overall health and hydration status, but they are not specifically related to the client’s anemia or the symptom of fatigue. Electrolyte imbalances typically do not cause fatigue related to anemia, so this is not the primary laboratory value to review in this context.
Choice D reason: Liver enzymes are important for assessing liver function and potential liver damage, but they are not directly related to iron deficiency anemia or the symptom of fatigue. While it is important to monitor liver health, especially if the client is on medications that affect the liver, the complete blood count is more relevant to the symptoms described.
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