The health care provider has ordered a fluid deprivation test for a client suspected of having diabetes insipidus. During the test, the nurse should prioritize what assessments?

Color, warmth, movement, and sensation of extremities

Breath sounds and bowel sounds

Heart rate and blood pressure

Temperature and oxygen saturation

Answer and Explanation

The Correct Answer is C

Choice A reason: Assessing color, warmth, movement, and sensation of extremities is relevant for neurological or vascular conditions, not a fluid deprivation test. This test induces dehydration to evaluate ADH function, which primarily affects fluid status and cardiovascular parameters, not peripheral limb function, making these assessments less critical for monitoring during the test.

Choice B reason: Breath and bowel sounds are not prioritized during a fluid deprivation test. The test assesses the body’s ability to concentrate urine under dehydration stress, primarily impacting fluid and cardiovascular status. Respiratory and gastrointestinal functions are not directly affected by short-term fluid restriction in diagnosing diabetes insipidus.

Choice C reason: Heart rate and blood pressure are critical during a fluid deprivation test, as dehydration from fluid restriction can cause hypovolemia, leading to tachycardia and hypotension. Monitoring these parameters ensures patient safety and detects cardiovascular responses to fluid loss, which are key to evaluating the severity of diabetes insipidus.

Choice D reason: Temperature and oxygen saturation are secondary in a fluid deprivation test. Dehydration may cause slight temperature changes, but these are not primary indicators. Oxygen saturation remains stable unless severe hypovolemia leads to shock, which is rare in a controlled setting, making these assessments less critical than cardiovascular monitoring.

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Correct Answer is D

Explanation

Reasoning:

Choice A reason: Homonymous hemianopsia causes loss of half the visual field, affecting object recognition due to visual impairment, not cognitive processing. The client’s need to inspect clothing to identify it suggests a sensory processing deficit, not a visual field loss, making agnosia more likely.

Choice B reason: Receptive aphasia impairs language comprehension, affecting the ability to understand spoken or written words, not object recognition. The client’s ability to identify clothing by inspection, not language, points to a sensory processing issue, ruling out aphasia as the primary impairment.

Choice C reason: Hemiplegia, or paralysis of one side, affects movement, not object recognition. The client’s difficulty identifying clothing is cognitive, not motor, as they can manipulate items but need visual inspection to understand them, indicating agnosia rather than a physical impairment like hemiplegia.

Choice D reason: Agnosia, a post-stroke impairment, prevents recognition of objects despite intact sensory input. The client’s need to inspect clothing to identify it suggests visual agnosia, where the brain fails to process familiar objects, matching the described behavior and indicating a perceptual deficit from stroke.

A. Confusion and diarrhea B. Hypertension and weight gain without edema C. Pulmonary congestion and muscle cramps D. Dyspnea and hypertension

Correct Answer is D

Explanation

Reasoning:

Choice A reason: Confusion may occur in SIADH due to hyponatremia-induced cerebral edema, but diarrhea is not a typical sign of fluid overload. Diarrhea causes fluid loss, which is opposite to the water retention seen in SIADH, making this combination less indicative of fluid overload compared to cardiovascular or respiratory signs.

Choice B reason: Hypertension may occur in SIADH due to fluid overload, but weight gain without edema is less specific. SIADH often causes subtle fluid retention without overt edema, but weight gain alone does not fully indicate fluid overload, as it lacks the respiratory or cardiovascular specificity of dyspnea and hypertension.

Choice C reason: Pulmonary congestion may indicate fluid overload in SIADH, as excess water can lead to pulmonary edema. However, muscle cramps are more related to hyponatremia than fluid overload itself. This combination is less precise than dyspnea and hypertension for identifying fluid overload in this context.

Choice D reason: Dyspnea and hypertension are key indicators of fluid overload in SIADH. Excessive ADH causes water retention, increasing blood volume, which raises blood pressure. Fluid accumulation in the lungs can cause dyspnea, reflecting pulmonary edema, a serious complication of fluid overload in SIADH, making this the most accurate finding.

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The health care provider has ordered a fluid deprivation test for a client suspected of having diabetes insipidus. During the test, the nurse should prioritize what assessments?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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