A nurse is reviewing data for a client who has a head injury. Which of the following findings should indicate to the nurse that the client might have diabetes insipidus?
Urine output 800 mL/hr
Blood glucose 198 mg/dL
Serum sodium 145 mEq/L
Urine specific gravity 1.028
The Correct Answer is A
Choice A Reason: Urine output 800 mL/hr is a sign of diabetes insipidus, as it indicates that the kidneys are producing large amounts of diluted urine due to the lack of antidiuretic hormone (ADH) or its action.
Choice B Reason: Blood glucose 198 mg/dL is not a sign of diabetes insipidus, but it may indicate diabetes mellitus or hyperglycemia.
Choice C Reason: Serum sodium 145 mEq/L is not a sign of diabetes insipidus, but it is within the normal range (135-145 mEq/L).
Choice D Reason: Urine specific gravity 1.028 is not a sign of diabetes insipidus, but it indicates concentrated urine due to dehydration or other causes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: Encouraging deep-breathing exercises is not the most appropriate nursing intervention, as it may not reduce fatigue and may increase respiratory effort.
Choice B Reason: Providing a relaxing warm bath is not the most appropriate nursing intervention, as it may worsen fatigue and increase the risk of heat intolerance and dehydration.
Choice C Reason: Scheduling periods of rest in between activities is the most appropriate nursing intervention, as it helps to conserve energy, prevent exhaustion, and promote recovery.
Choice D Reason: Administering multivitamins is not the most appropriate nursing intervention, as it may not improve fatigue and may cause adverse effects or interactions with other medications.
Correct Answer is ["A","C","E"]
Explanation
Choice A Reason: History of alcohol abuse is an additional information that the nurse should obtain from this client, as it may indicate liver damage or cirrhosis, which can cause clay-colored stool due to reduced bile production or flow.
Choice B Reason: Intolerance to fatty foods is not an additional information that the nurse should obtain from this client, as it does not relate to clay-colored stool, but it may indicate gallbladder disease or malabsorption.
Choice C Reason: Pain in the RUQ radiating to the shoulder is an additional information that the nurse should obtain from this client, as it may indicate gallstone obstruction or inflammation, which can cause clay-colored stool due to blocked bile ducts.
Choice D Reason: Pain in the McBurney's point is not an additional information that the nurse should obtain from this client, as it does not relate to clay-colored stool, but it may indicate appendicitis or diverticulitis.
Choice E Reason: Bleeding ulcer is an additional information that the nurse should obtain from this client, as it may indicate upper gastrointestinal bleeding, which can cause clay-colored stool due to digested blood.
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