A nurse is providing care for an older adult client who has diabetes insipidus (DI). The nurse should monitor the client for which of the following neurological effects?

Hypotension

Poor skin turgor

Ataxia

Dilute urine

Answer and Explanation

The Correct Answer is C

Choice A reason: Hypotension
Hypotension, or low blood pressure, can be a consequence of dehydration, which is a common complication of DI due to the excessive loss of water. However, hypotension is not a direct neurological effect of DI. It is more of a circulatory system response to the changes in fluid volume within the body.

Choice B reason: Poor skin turgor
Poor skin turgor is an indicator of dehydration, which can occur in DI due to the large volume of urine excreted. Skin turgor refers to the skin's ability to change shape and return to normal (elasticity), and it becomes less elastic when the body is dehydrated. While this is an important sign to monitor, it is not a neurological effect.

Choice C reason: Ataxia
Ataxia, which is a lack of muscle coordination affecting speech, eye movements, the ability to swallow, walking, picking up objects, and other voluntary movements, can be a neurological effect of DI if severe dehydration and electrolyte imbalance affect the brain. Symptoms such as confusion and muscle cramps can also be associated with ataxia, making it a relevant neurological effect to monitor in a client with DI.

Choice D reason: Dilute urine
Dilute urine is a primary symptom of DI, not a neurological effect. It is the result of the kidneys' inability to concentrate urine due to a deficiency in the anti-diuretic hormone (ADH) or the kidneys' response to ADH. Monitoring urine concentration is crucial in managing DI, but it does not represent a neurological effect.

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Correct Answer is C

Explanation

Choice A reason: Hypertension
Hypertension, or high blood pressure, is not typically an expected finding in hypovolemic shock. In fact, one would expect the opposite, hypotension, due to the decreased circulating blood volume. Hypertension might be present in the initial stages due to compensatory mechanisms, but as the condition progresses, blood pressure usually drops.

Choice B reason: Bradypnea
Bradypnea, or abnormally slow breathing, is not a common finding in hypovolemic shock. Instead, tachypnea, or rapid breathing, may be observed as the body attempts to compensate for reduced oxygen delivery to tissues.

Choice C reason: Oliguria
Oliguria, or low urine output, is an expected finding in hypovolemic shock. As the blood volume decreases, the kidneys receive less blood flow, leading to reduced urine production. This is a protective mechanism to conserve body fluids, but it also indicates the severity of fluid loss and the need for urgent intervention.

Choice D reason: Flushing of the skin
Flushing of the skin is not an expected finding in hypovolemic shock. Instead, the skin may appear pale, cool, and clammy due to vasoconstriction and reduced blood flow to the periphery as the body prioritizes blood flow to vital organs.

A. Massage over erythematous bony prominences. B. Minimize skin exposure to moisture. C. Use pillows to keep heels off the bed surface. D. Implement a turning schedule every 4 hours. E. Keep the client's skin dry with powder.

Correct Answer is ["B","C"]

Explanation

The correct answer is b. Minimize skin exposure to moisture and c. Use pillows to keep heels off the bed surface.

Choice A reason:

a. Massage over erythematous bony prominences: This is incorrect because massaging erythematous (reddened) areas can cause further tissue damage and exacerbate skin breakdown.

Choice B reason:

b. Minimize skin exposure to moisture: This is correct. Moisture can lead to skin maceration, increasing the risk of skin breakdown. Keeping the skin dry helps maintain its integrity.

Choice C reason:

c. Use pillows to keep heels off the bed surface: This is correct. Elevating the heels reduces pressure on them, preventing pressure ulcers.

Choice D reason:

d. Implement a turning schedule every 4 hours: This is incorrect. To prevent pressure injuries, turning should be done every 2 hours, not every 4 hours.

Choice E reason:

e. Keep the client’s skin dry with powder: This is incorrect. Powder can cause skin irritation and breakdown.

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A nurse is providing care for an older adult client who has diabetes insipidus (DI). The nurse should monitor the client for which of the following neurological effects?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

Correct Answer is C

Explanation

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Correct Answer is ["B","C"]

Explanation

Choice A reason:

Choice B reason:

Choice C reason:

Choice D reason:

Choice E reason:

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