A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor.
Which potential complication should the nurse monitor closely?
Ketonuria.
Peripheral edema.
Hypokalemia.
Elevated blood pressure.
The Correct Answer is C
Choice A rationale:
Ketonuria is not a common complication of diabetes insipidus. Ketonuria is associated with diabetes mellitus, a different condition that results in the accumulation of ketones in the urine due to insufficient insulin.
Choice B rationale:
Peripheral edema is also an unlikely complication of diabetes insipidus. Diabetes insipidus is characterized by excessive thirst and urination, not fluid retention or peripheral edema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale:
Observing for extrapyramidal symptoms, such as dystonia, is the most important intervention immediately after seclusion because haloperidol is an antipsychotic medication known to have the potential for causing extrapyramidal side effects. Identifying and managing these side effects promptly is crucial to ensure the client's safety.
Choice A rationale:
Releasing the client as soon as composure is regained may not be safe if the client is still at risk of harming themselves or others. Monitoring for the resolution of symptoms and stabilization is important before releasing the client.
Choice C rationale:
Securing the room with padded walls and minimal furnishings is not the immediate priority. While seclusion rooms should be safe and comfortable, observing for potential side effects takes precedence.
Choice D rationale:
Providing one-on-one observation at all times is a resource-intensive intervention and may not be necessary for all clients. Observing for extrapyramidal symptoms is more targeted and appropriate in this scenario.
Correct Answer is B
Explanation
Choice A rationale:
Serum blood glucose (BG) level is not directly related to the presence of purulent drainage at a burn wound site. Elevated BG levels might be seen in clients with diabetes or as a stress response, but they are not the primary indicator of infection or wound complications.
Choice C rationale:
Serum albumin levels can be relevant in assessing nutritional status and the body's ability to heal wounds. However, they do not directly indicate the presence of infection or purulent drainage. Low serum albumin levels may be seen in clients with malnutrition but do not provide immediate information about the wound.
Choice D rationale:
Hematocrit measures the percentage of red blood cells in the blood and is not directly related to the presence of purulent drainage at a burn wound site. Elevated hematocrit may indicate dehydration or hemoconcentration but does not specifically address the issue of wound infection.
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