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 B
Explanation
Abdominal discomfort an hour after a meal is a common symptom of a gastric ulcer because the stomach is where food is initially processed, and stomach acid is most concentrated. In contrast, duodenal ulcers typically cause pain 2-3 hours after meals, as food moves out of the stomach and into the duodenum, where it encounters duodenal acid.
A positive stool occult blood test is a non-specific finding that can be caused by many gastrointestinal conditions, including peptic ulcers. It does not indicate the location of the ulcer.
The number of ulcers the client has had in the past does not indicate the location of the current ulcer.
Normal hemoglobin and hematocrit levels do not provide information about the location of the ulcer.
Correct Answer is B
Explanation
The statement "I had the stomach flu earlier this week and couldn't take the hydrocortisone" indicates that the patient may not be adhering to their prescribed medication regimen, which can lead to an Addisonian crisis. Therefore, the nursing diagnosis of ineffective therapeutic regimen management related to lack of knowledge of management of the condition is appropriate.
Addison’s disease is a condition in which the adrenal glands do not produce enough cortisol and aldosterone. Hydrocortisone is a glucocorticoid medication that is often used to replace the cortisol that the adrenal glands are not producing. In the Addisonian crisis, the body is unable to produce the necessary levels of cortisol and aldosterone, which can lead to potentially life-threatening complications such as hypotension, dehydration, and electrolyte imbalances.
The other statements may indicate areas where patient education is needed, but they do not directly relate to the immediate risk of an Addisonian crisis.
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