Which data warrants the most immediate intervention by the nurse for a client with diabetes insipidus (DI)? Reference Range: Sodium [136 to 145 mEq/L (136 to 145 mmol/L)].
Dry skin with inelastic turgor.
Apical rate of 110 beats/minute.
Serum sodium of 185 mEq/L (185 mmol/L).
Polyuria and excessive thirst.
The Correct Answer is C
Choice A reason: Dry skin and inelastic turgor reflect dehydration in DI from antidiuretic hormone deficiency, causing water loss. This is less urgent than hypernatremia (185 mEq/L), which dehydrates brain cells, risking seizures or coma, requiring immediate fluid correction to prevent neurological damage in this critical condition.
Choice B reason: Tachycardia (110 beats/minute) compensates for hypovolemia in DI, where water loss reduces preload, triggering sympathetic activation. This is less critical than hypernatremia (185 mEq/L), which causes cerebral dehydration, necessitating urgent hypotonic fluids to prevent neurological complications, making heart rate secondary.
Choice C reason: Serum sodium of 185 mEq/L indicates severe hypernatremia in DI, where water loss concentrates sodium, dehydrating neurons and risking seizures or coma. Immediate IV hypotonic fluids (e.g., 5% dextrose) correct osmolarity, preventing life-threatening cerebral complications, addressing the urgent pathophysiological crisis in DI.
Choice D reason: Polyuria and thirst are hallmark DI symptoms from water loss but expected and less urgent than hypernatremia (185 mEq/L), which threatens neurological function via osmotic brain injury. Correcting sodium is critical to prevent seizures, making these symptoms secondary to urgent electrolyte management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Reviewing vascular disease history provides context but does not confirm perfusion status. An absent DP pulse may indicate arterial occlusion, risking ischemia. Doppler assessment directly evaluates blood flow, detecting patency, critical for guiding interventions to ensure limb perfusion, making history review secondary.
Choice B reason: Marking an auscultated DP pulse is incorrect, as pulses are palpated or Doppler-assessed, not auscultated. Auscultation applies to heart or lungs. Doppler confirms arterial flow, addressing absent pulse’s potential occlusion, making this inaccurate compared to the precise Doppler technique.
Choice C reason: Capillary refill evaluates perfusion but is less specific than Doppler, which confirms arterial flow. Prolonged refill may indicate ischemia, but absent DP pulse suggests arterial compromise. Doppler acoustically detects flow, diagnosing critical limb ischemia, making it the priority over indirect perfusion measures.
Choice D reason: Using Doppler to assess DP pulse is critical, as an absent pulse may indicate occlusion from peripheral arterial disease, risking ischemia. Doppler detects blood flow, confirming patency or obstruction, guiding urgent interventions like angiography, ensuring limb viability by addressing vascular compromise directly.
Correct Answer is B
Explanation
Choice A reason: Administering warfarin with an INR of 4.8 is dangerous, as it exceeds the therapeutic range (2.0–3.0), indicating excessive anticoagulation. This risks bleeding, as warfarin inhibits vitamin K-dependent clotting factors. Notifying the provider ensures dose adjustment or reversal, preventing hemorrhage, making this action unsafe.
Choice B reason: An INR of 4.8 indicates over-anticoagulation in atrial fibrillation, increasing bleeding risk due to warfarin’s inhibition of clotting factors. Notifying the provider is critical for dose reduction or vitamin K administration, addressing the pathophysiological risk of hemorrhage, ensuring patient safety and preventing life-threatening complications.
Choice C reason: Encouraging green leafy vegetables, high in vitamin K, counteracts warfarin, lowering INR, but is inappropriate without provider guidance at INR 4.8, risking bleeding. Provider notification ensures controlled management, as unregulated dietary changes disrupt anticoagulation stability, making this action potentially harmful.
Choice D reason: Monitoring for bleeding is important but secondary to notifying the provider at INR 4.8, indicating critical over-anticoagulation. Immediate provider intervention adjusts warfarin or administers reversal agents, preventing hemorrhage. Monitoring delays urgent action needed to correct the clotting factor imbalance, making it less immediate.
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