A nurse is assessing a client diagnosed with diabetes insipidus. The nurse should expect which of the following assessment findings?
Bradycardia
Bounding peripheral pulses
Urine specific gravity 1.002
Normal urine output
The Correct Answer is C
A. Bradycardia is not a common finding in diabetes insipidus; rather, patients may experience tachycardia due to volume depletion.
B. Bounding peripheral pulses may occur in conditions with fluid overload, which is not typical in diabetes insipidus where there is a lack of fluid retention.
C. Urine specific gravity of 1.002 indicates dilute urine, which is consistent with diabetes insipidus, where the body fails to concentrate urine due to insufficient antidiuretic hormone (ADH).
D. Clients with diabetes insipidus typically experience polyuria, resulting in increased urine output rather than normal levels
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Correct Answer is C
Explanation
A. Diplopia is a concerning symptom but does not indicate immediate deterioration in neurological status like a change in GCS does.
B. Ataxia is also significant but is less acute than a drop in GCS score.
C. A change in the Glasgow Coma Scale score from 13 to 11 indicates a worsening level of consciousness and necessitates immediate reporting, as it may suggest increased intracranial pressure or other complications.
D. A decrease in heart rate from 76 to 69 bpm is not significant enough in the context of TBI to warrant immediate reporting, as it remains within a normal range.
Correct Answer is C
Explanation
A. The supine position can increase ICP and is not recommended for clients with elevated ICP.
B. Instructing the client to pull themselves up may increase ICP due to straining.
C. Log rolling helps maintain spinal alignment and minimizes abrupt head movement, which is essential in managing ICP.
D. Sitting with legs dangling may cause a sudden shift in intracranial pressure and is not advised for these clients.