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:
Asking questions about the information on her postoperative care pamphlet is a positive behavior indicating that the client is proactive in understanding her care and recovery process. It shows engagement and a desire to comply with medical advice, which is beneficial for recovery.
Choice B reason:
Refusing to look at the dressing or surgical incision may indicate psychological distress and difficulty in accepting the physical changes following a mastectomy. This behavior can be a sign of avoidance and a potential struggle with body image and the emotional impact of breast loss. It's important for healthcare providers to recognize this as a call for psychological support and possible referral to counseling services.
Choice C reason:
Performing arm exercises once or twice a day is typically recommended as part of the postoperative care after a mastectomy to prevent stiffness and improve mobility. This behavior suggests that the client is following postoperative instructions and actively participating in her recovery.
Correct Answer is ["A","D","E"]
Explanation
Choice B reason:
Sleeping on a soft mattress is not recommended for preventing low back pain. A medium-firm mattress often provides better support for the spine. A soft mattress may allow the body to sink in too deeply, causing misalignment of the spine during sleep.
Choice C reason:
Applying heat for 10 minutes every hour is not a standard recommendation for preventing low back pain. While heat therapy can help relax muscles and relieve pain, it is typically advised to apply heat for longer periods, such as 15-20 minutes, and not as frequently as every hour.
Choice D reason:
Sleeping in a side-lying position with flexed knees can help maintain the natural curve of the spine and minimize back strain. This position can also reduce pressure on the back and is often recommended for those with low back pain.
Choice E reason:
Trying padded shoe insoles can help minimize back strain by providing additional support and cushioning for the feet, which can improve alignment and reduce the impact on the back during walking or standing.
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