The nurse is assessing a client with a head injury Which finding would indicate that the client is developing diabetes insipidus?

Urine glucose, high

Urine specific gravity, 1.001

Urine output, 50 ml/hr

Urine protein, high

Answer and Explanation

The Correct Answer is B

A. Urine glucose, high: High urine glucose would suggest hyperglycemia, typically seen in diabetes mellitus, not diabetes insipidus.

B. Urine specific gravity, 1.001: Diabetes insipidus results in excessive urine output with a low specific gravity (dilute urine), reflecting the inability to concentrate urine.

C. Urine output, 50 ml/hr: This is a relatively low urine output, which does not indicate diabetes insipidus. Diabetes insipidus is characterized by very high urine output, often greater than 3 liters per day.

D. Urine protein, high: High urine protein could suggest kidney disease or glomerular injury, not diabetes insipidus.

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Correct Answer is B

Explanation

A. Decerebrate posturing: This involves extension and outward rotation of the arms, which is not observed here.

B. Decorticate posturing: Internal rotation, adduction, and flexion of the arms are characteristic of decorticate posturing, indicating damage to the corticospinal tract.

C. Flexion withdrawal: This refers to pulling away from a painful stimulus and does not involve the described pattern of movement.

D. Localization of pain: This is an intentional movement toward the source of pain, which is not demonstrated in this scenario.

A. Heart rate of 134 bpm B. Mild shortness of breath C. Three premature ventricular contractions in a row D. Blood pressure 152/88 mmHg

Correct Answer is C

Explanation

A. Heart rate of 134 bpm. A heart rate of 134 bpm is expected during a cardiac stress test, as the goal is to increase the heart rate to a target range to evaluate cardiac function under stress.

B. Mild shortness of breath. Mild shortness of breath is a common response to exercise and is not an indication to stop the test unless it becomes severe or is accompanied by other concerning symptoms like chest pain or cyanosis.

C. Three premature ventricular contractions in a row indicate a potential serious arrhythmia (ventricular tachycardia), which is a contraindication for continuing the stress test. This finding could place the client at risk for life-threatening cardiac events, such as ventricular fibrillation.

D. Blood pressure 152/88 mmHg. This is a slightly elevated but normal physiological response to exercise and does not warrant discontinuation of the test unless the blood pressure rises to dangerously high levels (e.g., >200/110 mmHg).

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The nurse is assessing a client with a head injury Which finding would indicate that the client is developing diabetes insipidus?

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