A nurse suspects a client has diabetes insipidus. What are the priority interventions? Select all that apply.
Monitor for hypernatremia.
Monitor neuro status.
Monitor for hyponatremia.
Monitor urine specific gravity.
Monitor strict I&O.
Correct Answer : A
Choice A: Monitor for hypernatremia.
Hypernatremia, or high sodium levels in the blood, is a common complication of diabetes insipidus due to excessive water loss and insufficient water intake. Monitoring for hypernatremia involves regular blood tests to check sodium levels. Symptoms of hypernatremia include extreme thirst, confusion, muscle twitching, and seizures. Early detection and management are crucial to prevent severe complications.
Choice B: Monitor neuro status.
Monitoring neurological status is essential in patients with diabetes insipidus because severe hypernatremia can lead to neurological symptoms such as confusion, irritability, seizures, and even coma. Regular assessments of mental status, level of consciousness, and neurological function help in early detection of complications and timely intervention.
Choice C: Monitor for hyponatremia.
While hyponatremia (low sodium levels) is less common in diabetes insipidus, it can occur if there is excessive water intake without adequate sodium replacement. Symptoms include headache, nausea, vomiting, confusion, and seizures. Monitoring sodium levels helps in maintaining a balance and preventing complications.
Choice D: Monitor urine specific gravity.
Urine specific gravity measures the concentration of solutes in the urine. In diabetes insipidus, urine is typically very dilute, with a specific gravity of less than 1.005. Regular monitoring helps in assessing the effectiveness of treatment and the patient’s hydration status. It also aids in differentiating diabetes insipidus from other conditions with similar symptoms.
Choice E: Monitor strict I&O.
Strict monitoring of intake and output (I&O) is crucial in managing diabetes insipidus. This involves accurately measuring all fluids consumed and excreted to ensure proper hydration and electrolyte balance. It helps in identifying trends in fluid loss and guiding appropriate fluid replacement therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is J
Explanation
Choice A Reason:
Gaining weight can be an indicator of improved nutrition, but it does not directly address the client’s ability to swallow safely and effectively. Weight gain could be due to other factors such as fluid retention or changes in metabolism. Therefore, while it is a positive outcome, it is not the best indicator of improved swallowing function.
Choice B Reason:
Choosing preferred items from the menu indicates that the client is engaged in their meal planning and has an appetite. However, it does not directly measure the client’s ability to swallow safely. The client might still have difficulty swallowing even if they are choosing their preferred foods.
Choice C Reason:
Clear understanding and articulation are important for communication and can indicate cognitive improvement. However, this choice does not directly relate to the client’s swallowing ability. The primary concern in this scenario is the client’s ability to swallow safely, not their communication skills.
Choice D Reason:
Eating 75 to 100% of all meals and snacks is the best indicator that the client has improved their swallowing ability. This choice directly measures the client’s ability to consume food and liquids safely and effectively. It shows that the client can manage their meals without significant difficulty, which is the primary goal of the intervention.
Correct Answer is A
Explanation
Choice A Reason:
Increased serum amylase is a key indicator of acute pancreatitis. Amylase is an enzyme produced by the pancreas to help digest carbohydrates. In cases of acute pancreatitis, the pancreas becomes inflamed, leading to the release of amylase into the bloodstream. Elevated levels of serum amylase, typically more than three times the upper limit of normal, are a strong indication of acute pancreatitis. This enzyme level usually rises within a few hours of the onset of pancreatitis and can remain elevated for several days.
Choice B Reason:
Increased serum calcium is not typically associated with acute pancreatitis. In fact, acute pancreatitis can often lead to hypocalcemia (low calcium levels) due to fat saponification in the pancreas, where calcium binds with fatty acids. Therefore, an increase in serum calcium would not be expected in a patient with acute pancreatitis. Monitoring calcium levels is important, but an increase is not a diagnostic marker for this condition.
Choice C Reason:
Decreased WBC (white blood cell count) is not a characteristic finding in acute pancreatitis. On the contrary, acute pancreatitis often leads to an elevated WBC count due to the inflammatory response in the body. Leukocytosis (increased WBC) is a common finding in many inflammatory and infectious conditions, including acute pancreatitis. Therefore, a decreased WBC count would not be expected and does not support the diagnosis of acute pancreatitis.
Choice D Reason:
Decreased serum lipase is incorrect. Similar to amylase, lipase is another enzyme produced by the pancreas, which helps in the digestion of fats. In acute pancreatitis, serum lipase levels also increase significantly, often more than three times the upper limit of normal. Lipase levels tend to rise slightly later than amylase but remain elevated for a longer period, making it a useful marker for diagnosing acute pancreatitis. Therefore, decreased serum lipase would not be expected in this condition.
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