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. Platelet count, blood glucose levels, and white blood cell (WBC) count B. Thrombin time, calcium levels, and potassium levels C. Platelet count, prothrombin time, and partial thromboplastin time D. Fibrinogen level, WBC, and platelet count

Correct Answer is C

Explanation

Reasoning:

Choice A reason: Platelet count and WBC count are relevant, but blood glucose levels are not specific to DIC. DIC involves widespread clotting and bleeding, depleting platelets and coagulation factors, affecting clotting times. Glucose levels are unrelated to the coagulopathy central to DIC’s pathophysiology, making this set less comprehensive.

Choice B reason: Thrombin time is relevant to DIC, but calcium and potassium levels are not primary indicators. Calcium may affect clotting in specific contexts, but DIC primarily involves consumption of platelets and clotting factors, prolonging prothrombin and partial thromboplastin times, making these more critical parameters.

Choice C reason: Platelet count, prothrombin time (PT), and partial thromboplastin time (PTT) are key in DIC monitoring. DIC causes widespread microthrombi, consuming platelets and clotting factors, leading to low platelets and prolonged PT/PTT. These parameters directly reflect the coagulopathy and bleeding risk, making them essential for diagnosis and management.

Choice D reason: Fibrinogen level and platelet count are important in DIC, as both are consumed in widespread clotting. However, WBC count is less specific, as it reflects infection or inflammation, not coagulopathy. PT and PTT better capture the clotting factor depletion central to DIC’s pathophysiology.

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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 C

Explanation

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