A nurse is providing care for an older adult client who has diabetes insipidus (DI). The nurse should monitor the client for which of the following neurological effects?
Hypotension
Poor skin turgor
Ataxia
Dilute urine
The Correct Answer is C
Choice A reason: Hypotension
Hypotension, or low blood pressure, can be a consequence of dehydration, which is a common complication of DI due to the excessive loss of water. However, hypotension is not a direct neurological effect of DI. It is more of a circulatory system response to the changes in fluid volume within the body.
Choice B reason: Poor skin turgor
Poor skin turgor is an indicator of dehydration, which can occur in DI due to the large volume of urine excreted. Skin turgor refers to the skin's ability to change shape and return to normal (elasticity), and it becomes less elastic when the body is dehydrated. While this is an important sign to monitor, it is not a neurological effect.
Choice C reason: Ataxia
Ataxia, which is a lack of muscle coordination affecting speech, eye movements, the ability to swallow, walking, picking up objects, and other voluntary movements, can be a neurological effect of DI if severe dehydration and electrolyte imbalance affect the brain. Symptoms such as confusion and muscle cramps can also be associated with ataxia, making it a relevant neurological effect to monitor in a client with DI.
Choice D reason: Dilute urine
Dilute urine is a primary symptom of DI, not a neurological effect. It is the result of the kidneys' inability to concentrate urine due to a deficiency in the anti-diuretic hormone (ADH) or the kidneys' response to ADH. Monitoring urine concentration is crucial in managing DI, but it does not represent a neurological effect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Lightheadedness is generally not an indication of effective treatment for dehydration. It is often a symptom of dehydration itself, as it can result from decreased blood volume and reduced blood flow to the brain. Effective rehydration should alleviate symptoms like lightheadedness, not present as an indication of it.
Choice B reason:
Decreased pulse pressure may indicate a drop in the volume of blood circulating through the body, which is not a sign of effective rehydration. Pulse pressure is the difference between systolic and diastolic blood pressure readings, and a narrow pulse pressure can be a sign of hypovolemia, or low blood volume, often due to dehydration.
Choice C reason:
Urine output of 75 mL in 1 hr can be considered within the normal range of urine output for an adult, which is typically about 0.5 to 1 mL/kg/hr⁵. This indicates that the kidneys are functioning and the body is excreting waste, suggesting effective rehydration.
Choice D reason:
A urine specific gravity of 1.038 is higher than the normal range of 1.005 to 1.030[^10^]. This indicates concentrated urine, which is commonly seen in dehydration as the body attempts to conserve water. Therefore, this is not an indication of effective treatment for dehydration.
Correct Answer is A
Explanation
Choice A reason:
In the case of burns to the face and chest, assessing for inhalation injuries is critical due to the potential for airway compromise. Inhalation injuries can lead to significant respiratory distress and are considered a high priority in burn care. Inspecting the mouth for soot, burns, or edema can provide immediate information about the potential for respiratory complications, which can be life-threatening.
Choice B reason:
While monitoring urine output is important in burn patients for assessing fluid balance and kidney function, it is not the immediate priority. The insertion of an indwelling urinary catheter can be performed after stabilizing the airway and ensuring the patient is breathing adequately.
Choice C reason:
A CBC count is important for evaluating the patient's overall health status and can indicate the presence of infection or anemia. However, it is not the first action to take in the emergency setting where immediate life-saving interventions are prioritized.
Choice D reason:
Administering intravenous pain medication is important for patient comfort and can facilitate further care, but it is not the first priority. The initial focus should be on life-saving measures such as securing the airway and assessing for inhalation injuries.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.