Nokea
What interventions should the nurse implement in caring for a client with diabetes insipidus (DI) following a head injury? Select all that apply.
- A. Providing adequate fluids within easy reach
- B. Reporting an increasing urine specific gravity
- C. Administering prescribed erythromycin
- D. Assessing for and reporting changes in neurological status
Correct Answer: A
Rationale: For diabetes insipidus (DI) post-head injury, providing fluids (A) prevents dehydration from polyuria. Increasing urine specific gravity (B) contradicts DI's dilute urine. Erythromycin (C) is unrelated. Neurological changes (D) are monitored but secondary. A is correct. Rationale: Fluid replacement matches DI's excessive output, a primary intervention per endocrine care standards, maintaining hydration.
You may also like to solve these questions
Which of the following is the appropriate nursing intervention for a patient with a terminal illness who is passing through the acceptance stage?
- A. Allowing the patient to cry
- B. Encouraging unrestricted visiting
- C. Explaining the patient what is being done
- D. Being around though not speaking
Correct Answer: D
Rationale: In Kübler-Ross's acceptance stage, patients often seek peace, preferring quiet presence over active intervention. Being nearby without speaking respects their emotional state, offering comfort without disruption. Crying aligns with earlier stages (e.g., depression), unrestricted visiting may overwhelm, and explaining procedures suits denial or bargaining. Nurses provide silent support, aligning with the patient's need for calm reflection, enhancing dignity and comfort in end-of-life care.
When a client's skin is dry, which of the following nursing interventions would be most helpful?
- A. Limit bathing to once or twice a week.
- B. Bathing is daily, but no soap is used.
- C. Bathing daily with mineral oil added to the water.
- D. Bathing with lotion instead of water.
Correct Answer: A
Rationale: Limiting bathing to once or twice weekly prevents further drying of already dry skin, preserving natural oils. Daily bathing, even without soap or with oil, risks exacerbation, and lotion isn't a bath substitute. Nurses apply this to maintain skin integrity.
An 8.5 lb, 6 oz infant is delivered to a diabetic mother. Which nursing intervention would be implemented when the neonate becomes jittery and lethargic?
- A. Administer insulin
- B. Administer oxygen
- C. Feed the infant glucose water (10%)
- D. Place infant in a warmer
Correct Answer: C
Rationale: Jitteriness and lethargy suggest hypoglycemia, common in infants of diabetic mothers; glucose water corrects this.
Too narrow cuff will cause what change in the Client's BP?
- A. True high reading
- B. True low reading
- C. False high reading
- D. False low reading
Correct Answer: C
Rationale: A narrow cuff e.g., under-sized overcompresses, yielding a false high BP e.g., 140/90 vs. true 120/80. True readings need proper fit; wide cuffs may lower falsely. Nurses select cuffs e.g., per arm size for accuracy, per measurement standards.
The nurse ensured Mr. Gary's bed rails were up. This is an example of?
- A. Patient safety
- B. Collaboration
- C. Health promotion
- D. Nursing informatics
Correct Answer: A
Rationale: Ensuring bed rails up is patient safety (A) harm prevention, per definition. Collaboration (B) teams, promotion (C) well-being, informatics (D) tech not safety-specific. A fits protective action, making it correct.