A client is being prepared for discharge. The client's discharge plan includes resuming the lower dose of lithium and continuing to take desmopressin in oral form. The nurse teaches the client about safety measures.
Click to indicate which client statements indicate teaching was effective related to management of diabetes insipidus and care. Each row must have only one option selected.
I will monitor my urine output and pay attention to the volume and color.
I will always wear my medical alert bracelet.
I will use the same scale and wear a similar amount of clothing when I take my weekly weight.
If I gain more than 2.2 lb (1 kg), I will go to the emergency department (ED).
If I become thirstier, I may need another dose of the medication.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}
- I will monitor my urine output and pay attention to the volume and color. Clients with DI must monitor urine output closely because polyuria and diluted urine indicate under-treatment, while sudden reduced output and darker urine may suggest fluid retention or excessive desmopressin dosing.
- I will always wear my medical alert bracelet. A medical alert bracelet is essential for emergency situations since DI can lead to severe dehydration and electrolyte imbalances if left untreated. It ensures that emergency responders are aware of the condition if the client is unable to communicate.
- I will use the same scale and wear a similar amount of clothing when I take my weekly weight. Monitoring body weight trends is crucial in DI management, as sudden weight gain may indicate fluid retention (over-treatment), while weight loss may suggest dehydration. Using a consistent method ensures accurate tracking.
- If I gain more than 2.2 lb (1 kg), I will go to the emergency department (ED). A sudden weight gain may suggest fluid retention from over-treatment, but mild fluctuations are not always an emergency. Instead, the client should report significant weight changes to their healthcare provider to assess medication adjustments.
- If I become thirstier, I may need another dose of the medication. While increased thirst may indicate under-treatment, self-adjusting the desmopressin dose is not recommended without consulting a healthcare provider. The client should track symptoms and report persistent thirst to determine if a dosage change is necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
A. Allow the family to touch and talk to the client. Family presence can provide emotional support for both the client and loved ones. Even though the client is sedated and has a low GCS, familiar voices and touch may reduce stress and anxiety. Allowing family interaction fosters comfort and connection during a critical time.
B. Reassess the client's vascular access. Maintaining secure and functional vascular access is essential for administering fluids, medications, and emergency interventions. Before transport, the nurse should confirm IV patency, ensure secure connections, and assess for signs of infiltration or malfunction. Trauma patients may require additional or larger bore IV access for fluid resuscitation or transfusion.
C. Assess neurological vital signs every 15 minutes. Frequent neurological assessments are crucial in head trauma patients with a low GCS to monitor for signs of worsening intracranial pressure, cerebral edema, or herniation. Changes in pupil response, motor function, or vital signs may indicate neurological deterioration requiring urgent intervention. Monitoring trends over time is necessary for early detection of complications.
D. Administer ophthalmic ointment. Clients with a low GCS often have impaired blinking, placing them at risk for corneal abrasions and dryness. Applying ophthalmic lubricant or artificial tears protects the cornea from injury and promotes eye health. Preventing exposure keratitis is essential in unconscious or sedated clients to avoid long-term ocular damage.
E. Apply soft bilateral wrist restraints for transport. Restraints are unnecessary because the client is sedated, intubated, and has a GCS of 6, meaning they cannot attempt self-extubation or interfere with care. Restraints should only be used if the client demonstrates a risk of harm. Standard transport protocols prioritize sedation and safety measures over restraints unless specifically required.
Correct Answer is A
Explanation
A. Administer a PRN bolus normal saline. The client is exhibiting signs of hypovolemic shock, including tachycardia (HR 110 bpm), tachypnea (RR 24), and hypotension (BP 80/50 mmHg) following massive gastrointestinal bleeding and multiple blood transfusions. Immediate fluid resuscitation with a normal saline bolus is the priority to restore intravascular volume, maintain perfusion, and prevent further deterioration.
B. Obtain a blood specimen for hematocrit. While monitoring hematocrit is important to assess ongoing blood loss, it does not take priority over treating the client’s current hypovolemia. A delay in resuscitation could worsen hypotension, decrease organ perfusion, and lead to shock.
C. Measure strict hourly urinary output. Monitoring urine output is important in assessing renal perfusion and fluid balance, but the client’s immediate need is volume replacement. If fluid resuscitation is delayed, renal perfusion could worsen, leading to acute kidney injury.
D. Switch oxygen delivery to a face mask. The client’s oxygen saturation is 94% on 4 L/min nasal cannula, indicating adequate oxygenation at this time. Increasing oxygen delivery is not immediately necessary compared to fluid resuscitation. However, if the client’s condition worsens, oxygen therapy adjustments may be needed.
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