Which of the information below obtained when caring for a patient who has been admited for evaluation of diabetes insipidus will be of greatest concern to the nurse?
The patient has a urine output of 800 ml/hr.
The patient is confused and lethargic.
The patient's urine specific gravity is 1.003.
The patient had a recent head injury.
The Correct Answer is B
Diabetes insipidus is a condition where the body is not able to regulate water balance properly, leading to excessive urine output and dehydration. The patient's urine output of 800 ml/hr (option A) and low urine specific gravity of 1.003 (option C) is consistent with diabetes insipidus and requires monitoring, but they are not as immediately concerning as the patient's confusion and lethargy.
Confusion and lethargy may indicate severe dehydration, electrolyte imbalances, or even brain swelling (if the patient had a recent head injury, as mentioned in option D). These symptoms require immediate attention to prevent further complications and ensure the patient's safety.
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Related Questions
Correct Answer is C
Explanation
Type 2 diabetes mellitus is a metabolic disorder characterized by high blood sugar levels resulting from decreased insulin secretion and/or increased insulin resistance. In type 2 diabetes, the body's cells become resistant to insulin, which is a hormone that helps regulate blood sugar levels by allowing glucose to enter cells for energy. As a result, the pancreas produces more insulin to compensate for the increased demand, but over time, the pancreas may not be able to keep up, and blood sugar levels rise.
Unlike type 1 diabetes, which is an autoimmune disorder in which the body's immune system destroys the insulin-producing cells in the pancreas, people with type 2 diabetes still produce insulin, but their body is not able to use it effectively. Therefore, type 2 diabetes can be managed through lifestyle changes, such as diet and exercise, and/or medication, such as oral hypoglycemic agents or insulin therapy.
Correct Answer is C
Explanation
The nurse should act on the order to insert a 16 French retention catheter first. The patient's markedly distended bladder and agitated and confused state suggest acute urinary retention, which can be relieved by inserting a catheter to drain the urine. This is a priority intervention as urinary retention can lead to serious complications such as bladder rupture, hydronephrosis, and renal failure. Once the catheter is inserted and the patient's bladder is drained, the healthcare provider can order further tests such as an IVP or blood tests to assess renal function. The order for lorazepam can be addressed after the catheter is inserted and the patient's urinary retention is addressed.
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