A nurse is caring for a patient with a head injury who has developed diabetes insipidus and is receiving desmopressin. The nurse understands the therapeutic outcome is a decrease in:

Specific gravity.

Level of consciousness.

Urine output.

Blood pressure.

Answer and Explanation

The Correct Answer is C

Choice A reason:

A decrease in specific gravity is not the primary therapeutic outcome of desmopressin in the treatment of diabetes insipidus. Desmopressin works by increasing water reabsorption in the kidneys, which leads to a decrease in urine output and an increase in urine concentration, reflected by an increase, not a decrease, in specific gravity.

Choice B reason:

A decrease in the level of consciousness is not an intended therapeutic outcome and would be concerning if observed. Desmopressin aims to control symptoms of diabetes insipidus, not alter the patient’s mental status.

Choice C reason:

A decrease in urine output is the primary therapeutic outcome of desmopressin in a patient with diabetes insipidus. Desmopressin mimics the action of antidiuretic hormone (ADH), leading to increased water reabsorption in the kidneys and reduced urine volume.

Choice D reason:

Desmopressin does not primarily aim to decrease blood pressure. Its main effect is on water reabsorption in the kidneys, thereby reducing urine output. While it can have some impact on blood pressure, this is not its primary therapeutic outcome.

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Correct Answer is A

Explanation

Choice A reason:

Flaccid paralysis and lack of sensation below the level of the injury are classic signs of spinal shock. Spinal shock is characterized by a temporary loss of all reflexes, motor, and sensory activity below the level of injury, which typically occurs immediately following the injury. Recognizing these signs is crucial for the timely management of the condition.

Choice B reason:

Hypotension, bradycardia, and warm extremities are more indicative of neurogenic shock rather than spinal shock. Neurogenic shock results from the loss of sympathetic tone following a spinal cord injury, leading to cardiovascular changes. These signs do not specifically indicate spinal shock.

Choice C reason:

The presence of hyperactive reflex activity below the level of the injury is not associated with spinal shock. Spinal shock involves the loss of reflex activity rather than hyperactivity. Hyperactive reflexes might develop later as the spinal cord recovers from the initial shock phase.

Choice D reason:

Severe headache, hypertension, and flushed face are symptoms more commonly associated with autonomic dysreflexia, not spinal shock. Autonomic dysreflexia occurs in patients with spinal cord injuries at or above the T6 level and is a response to a noxious stimulus below the level of injury. These symptoms are not indicative of spinal shock.

A. Assess the level at which the client has intact sensation B. Determine the level at which the client has retained mobility C. Monitor respiratory effort and oxygen saturation level D. Check the blood pressure and pulse for signs of spinal shock

Correct Answer is C

Explanation

Choice A reason:

Assessing the level at which the client has intact sensation is important in the overall management of a spinal cord injury. However, it is not the immediate priority in an emergency setting. Ensuring the client's respiratory function and oxygenation is the first concern to stabilize the patient.

Choice B reason:

Determining the level at which the client has retained mobility is part of the assessment of a spinal cord injury but is secondary to monitoring and ensuring adequate respiratory effort and oxygen saturation. Mobility can be evaluated once the patient's vital signs are stable.

Choice C reason:

Monitoring respiratory effort and oxygen saturation level is the priority nursing action for a client with a spinal cord injury at the C3 to C4 level. Injuries at this level can impair the diaphragm and other muscles essential for breathing. Ensuring that the patient has adequate respiratory function and oxygenation is critical to prevent respiratory failure.

Choice D reason:

Checking blood pressure and pulse for signs of spinal shock is important, but the immediate priority is to ensure that the patient is breathing effectively and has sufficient oxygen saturation. Respiratory compromise can occur quickly with high-level spinal cord injuries, making it the most urgent concern.

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A nurse is caring for a patient with a head injury who has developed diabetes insipidus and is receiving desmopressin. The nurse understands the therapeutic outcome is a decrease in:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with a neck fracture at the C3 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During the initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding:

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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