The nurse is caring for a patient with a traumatic brain injury. Which assessment finding alerts the nurse to possible diabetes insipidus?
a. Headache
b. Confusion
c. Frequent urination
d. Elevated blood glucose
ANS: C
Edema or direct injury affects the posterior portion of the pituitary gland or hypothalamus. Inadequate release of antidiuretic hormone results in polyuria and, if the patient is awake, polydipsia. Fluid replacement and intravenous vasopressin are used to maintain fluid and electrolyte balance. A. B. Headache and confusion are symptoms of intracranial pressure (ICP). D. Elevated glucose is a sign of diabetes mellitus, not insipidus.
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The client is visiting the healthcare provider's office for a head-to-toe assessment. During the nurse's assessment of the client's skin, the nurse notes that the client is pale. Which assessment data may be related to the client's color?
Select all that apply. 1. Client's blood pressure is 96/62. 2. The client states, "I just smoked a cigarette before I came in the office." 3. The client's oxygen saturation level is 86% on room air. 4. The client states, "I have been diagnosed with osteoporosis." 5. The client states, "It is snowing again outside with a wind chill factor of -11 degrees Fahrenheit."
A young woman calls the clinic to report a fever and a funny rash with peeling skin on the palms of her hands and the soles of her feet. Which action by the nurse is most appropriate?
a. Make an appointment for her to be seen the next day at the clinic. b. Instruct her to take warm baths with oat-meal added to the water. c. Tell her to go to the emergency depart-ment immediately. d. Have her take acetaminophen (Tylenol) every 4 hours and drink fluids.
The nurse is caring for an older adult client who has fallen and fractured her hip. The client will have hip replacement surgery followed by extensive rehabilitation
The client confides in the nurse, "I feel like I don't have any control over anything anymore now that I am old." What is the nurse's best response? a. "I'll make sure that the physical and oc-cupational therapists see you after surgery to help get your strength back." b. "It's normal to feel this way, but hopefully you will be back on your feet after a stay in rehab." c. "It's important to control what you can right now, like making out your menu every day and working with the therap-ists." d. "I sense that you are feeling depressed about the situation. I will ask the doctor to prescribe an antidepressant for you."
Insulin is used to treat both types of diabetes. It acts by:
1. Increasing beta cell response to low blood-glucose levels 2. Stimulating hepatic glucose production 3. Increasing peripheral glucose uptake by skeletal muscle and fat 4. Improving the circulation of free fatty acids