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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
While it is true that many dietary supplements have not been tested and approved by the government, this is not the most critical information for a client taking nitroglycerin. The primary concern with dietary supplements is their potential interaction with other medications.
Choice B reason:
This is the most important statement for the nurse to include. Dietary supplements, especially those containing L-arginine or other compounds that affect blood flow, can have serious interactions with nitrates like nitroglycerin, potentially leading to dangerously low blood pressure.
Choice C reason:
The effectiveness of dietary supplements for erectile dysfunction varies, and there is indeed a lack of evidence for many of these products. However, the immediate concern for a client taking nitroglycerin is the risk of interaction, not the general effectiveness of supplements.
Choice D reason:
The cost and insurance coverage of dietary supplements can be a concern for clients, but it is not as critical as understanding the potential risks associated with their use alongside prescribed medications like nitroglycerin.
Correct Answer is C
Explanation
Choice A reason:
Clay-colored stools are typically associated with issues in the biliary system, such as bile duct obstruction or liver infections, and not directly with aspirin use. Aspirin does not typically cause a change in stool color unless there is gastrointestinal bleeding, which would more likely result in black, tarry stools.
Choice B reason:
Nystagmus, which is a vision condition characterized by repetitive, uncontrolled eye movements, is not a known side effect of aspirin. This condition is more commonly associated with neurological disorders, certain medications, or alcohol intoxication.
Choice C reason:
Tinnitus, or ringing in the ears, is a recognized adverse effect of aspirin, especially when taken in high doses or for a prolonged period. It occurs due to aspirin's effect on the inner ear's cochlear cells and can be a sign of salicylate toxicity.
Choice D reason:
Respiratory depression is not a typical side effect of aspirin. Aspirin can cause respiratory alkalosis in cases of overdose, but it does not depress respiration. Instead, it may cause hyperventilation due to stimulation of the respiratory center in the brain.
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