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 A

Explanation

Reasoning:

Choice A reason: Limiting visitor interaction reduces stimulation, which can increase intracranial pressure (ICP) in clients with cerebral aneurysms. Emotional or physical stress from interactions raises blood pressure, potentially increasing ICP and risking aneurysm rupture, making this a critical measure to maintain stability and prevent catastrophic bleeding.

Choice B reason: Interaction causing violence is not a typical concern in cerebral aneurysm management. Aneurysms may cause neurological symptoms, but violence is unrelated to visitor interactions. The primary risk is increased ICP from stimulation, not behavioral changes, making this an incorrect rationale for limiting visitors.

Choice C reason: Emotional distress from interactions may occur but is not the primary reason to limit visitors. The main concern in cerebral aneurysms is preventing ICP increases from stimulation, which could lead to rupture. Emotional impact on treatment adherence is secondary to this immediate physical risk.

Choice D reason: Migraines are not a direct consequence of visitor interactions in cerebral aneurysm cases. While headaches may occur, the primary concern is increased ICP from stimulation, which raises blood pressure and risks aneurysm rupture, not triggering migraines, which are unrelated to this context.

A. The client’s urinary catheter became occluded B. The client’s analgesia regimen was recently changed C. The client was not repositioned during the night shift D. The client received a blood transfusion

Correct Answer is A

Explanation

Reasoning:

Choice A reason: An occluded urinary catheter is the most likely trigger for autonomic dysreflexia in spinal cord injury above T6. Bladder distension stimulates sympathetic overactivity, causing hypertension and bradycardia. This noxious stimulus below the injury level disrupts autonomic regulation, making catheter occlusion a common precipitant of this condition.

Choice B reason: A changed analgesia regimen is unlikely to cause autonomic dysreflexia. Pain may contribute to discomfort, but dysreflexia typically results from visceral stimuli like bladder or bowel distension. Analgesia changes do not directly trigger the sympathetic overresponse characteristic of this life-threatening condition.

Choice C reason: Failure to reposition may cause pressure injuries but is less likely to precipitate autonomic dysreflexia. While discomfort from immobility can contribute, visceral stimuli like catheter occlusion are more direct triggers, as they strongly activate the sympathetic nervous system below the spinal injury level.

Choice D reason: A blood transfusion is not a common cause of autonomic dysreflexia. Transfusions may cause reactions like fever, but dysreflexia results from stimuli like bladder distension. Transfusion-related complications do not typically trigger the autonomic overresponse seen in spinal cord injury patients with dysreflexia.

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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

The nurse is caring for a client with a cerebral aneurysm. Why does the nurse limit the interaction of visitors or family members with the client who has an aneurysm?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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