A nurse suspects a client has diabetes insipidus. What are the priority interventions? Select all that apply.
Monitor for hypernatremia.
Monitor neuro status.
Monitor for hyponatremia.
Monitor urine specific gravity.
Monitor strict I&O.
Correct Answer : A
Choice A: Monitor for hypernatremia.
Hypernatremia, or high sodium levels in the blood, is a common complication of diabetes insipidus due to excessive water loss and insufficient water intake. Monitoring for hypernatremia involves regular blood tests to check sodium levels. Symptoms of hypernatremia include extreme thirst, confusion, muscle twitching, and seizures. Early detection and management are crucial to prevent severe complications.
Choice B: Monitor neuro status.
Monitoring neurological status is essential in patients with diabetes insipidus because severe hypernatremia can lead to neurological symptoms such as confusion, irritability, seizures, and even coma. Regular assessments of mental status, level of consciousness, and neurological function help in early detection of complications and timely intervention.
Choice C: Monitor for hyponatremia.
While hyponatremia (low sodium levels) is less common in diabetes insipidus, it can occur if there is excessive water intake without adequate sodium replacement. Symptoms include headache, nausea, vomiting, confusion, and seizures. Monitoring sodium levels helps in maintaining a balance and preventing complications.
Choice D: Monitor urine specific gravity.
Urine specific gravity measures the concentration of solutes in the urine. In diabetes insipidus, urine is typically very dilute, with a specific gravity of less than 1.005. Regular monitoring helps in assessing the effectiveness of treatment and the patient’s hydration status. It also aids in differentiating diabetes insipidus from other conditions with similar symptoms.
Choice E: Monitor strict I&O.
Strict monitoring of intake and output (I&O) is crucial in managing diabetes insipidus. This involves accurately measuring all fluids consumed and excreted to ensure proper hydration and electrolyte balance. It helps in identifying trends in fluid loss and guiding appropriate fluid replacement therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: You May Bring Some Music to Listen to for Distraction
Bringing music for distraction is generally not a standard instruction given before an EEG. While listening to music might help some patients relax, it is not a critical part of the preparation for the test. The primary focus of EEG preparation is to ensure accurate readings of brain activity, which can be influenced by various factors such as medication and sleep.
Choice B: Do Not Take Any Sedatives 12 to 24 Hours Before the Test
Avoiding sedatives before an EEG is crucial because these medications can alter brain activity and affect the test results. Sedatives can suppress the electrical activity in the brain, leading to inaccurate readings. Therefore, it is essential for patients to avoid taking any sedatives 12 to 24 hours before the test to ensure the EEG captures the brain’s natural activity.
Choice C: You Will Need to Have Someone to Drive You Home
This instruction is typically given if the patient is expected to be sedated or if the test involves procedures that might impair their ability to drive. However, for a standard EEG, patients are usually not sedated, and there is no need for someone to drive them home. This instruction is more relevant for other types of medical procedures that involve sedation.
Choice D: Please Do Not Have Anything to Eat or Drink After Midnight
Fasting is not a standard requirement for an EEG. Patients are generally allowed to eat and drink before the test. However, they are often advised to avoid caffeine as it can affect brain activity. The instruction to avoid food and drink after midnight is more commonly associated with procedures that require anesthesia or sedation, not an EEG.
Correct Answer is ["B","C","E","F"]
Explanation
Choice A Reason:
Weight gain is not typically associated with tuberculosis (TB). In fact, weight loss is a common symptom of TB due to the chronic nature of the infection and the body’s increased metabolic demands to fight the disease. Patients with TB often experience a loss of appetite and significant weight loss as the disease progresses.
Choice B Reason:
Low-grade fever is a common symptom of TB. The body’s immune response to the infection often results in a persistent low-grade fever, which can be one of the early signs of the disease. This fever is usually accompanied by other systemic symptoms such as night sweats and fatigue.
Choice C Reason:
Dyspnea, or difficulty breathing, can occur in patients with TB, especially if the infection has caused significant lung damage or if there is a large amount of fluid in the pleural space (pleural effusion). Dyspnea is a concerning symptom that indicates the need for further evaluation and treatment.
Choice D Reason:
Contusion, or bruising, is not a symptom associated with TB. TB primarily affects the lungs and can cause systemic symptoms, but it does not typically cause bruising. Contusions are more commonly associated with trauma or conditions that affect blood clotting.
Choice E Reason:
Lethargy, or a general sense of fatigue and weakness, is a common symptom of TB. The chronic nature of the infection and the body’s ongoing immune response can lead to significant fatigue. Patients with TB often feel tired and may have difficulty performing daily activities.
Choice F Reason:
Night sweats are a hallmark symptom of TB. Patients often experience drenching night sweats that can be quite severe. This symptom, along with fever and weight loss, is part of the classic triad of TB symptoms and is an important indicator for healthcare providers to consider TB in the differential diagnosis.
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