The nurse is caring for clients on a medical floor. Which client should be assessed first? 1. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who has a weight gain of 1.5 pounds since yesterday. 2. The client diagnosed with a pituitary tumor who has developed diabetes insipidus (DI) and has an intake of 1,500 mL and an output of 1,600 mL in the last 8 hours. 3. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who is having muscle twitching. 4. The client diagnosed with diabetes insipidus (DI) who is complaining of feeling tired after having to get up at night.
In this scenario, the client who should be assessed first is the client diagnosed with a pituitary tumor who has developed diabetes insipidus (DI) and has an intake of 1,500 mL and an output of 1,600 mL in the last 8 hours (option 2)
In this scenario, the client who should be assessed first is the client diagnosed with a pituitary tumor who has developed diabetes insipidus (DI) and has an intake of 1,500 mL and an output of 1,600 mL in the last 8 hours (option 2).
The reason for prioritizing this client’s assessment is the imbalance in fluid balance due to diabetes insipidus. Diabetes insipidus is a condition where the body is unable to properly regulate water balance, leading to excessive water loss through urine. In this case, the client has an output of 1,600 mL in the last 8 hours, which exceeds their intake of 1,500 mL. This can lead to dehydration and electrolyte imbalances and needs immediate attention.
The nurse should assess the client’s hydration status by monitoring their vital signs, urine output, and laboratory results such as electrolyte levels. It is essential to determine the extent of dehydration and any electrolyte imbalances that may have occurred.
Additionally, the nurse should also assess for signs and symptoms of dehydration such as dry mouth, decreased skin turgor, increased heart rate, low blood pressure, and dizziness. If the client’s condition worsens, interventions such as intravenous fluid administration may be necessary to correct the fluid imbalance.
Options 1, 3, and 4 involve clients with syndrome of inappropriate antidiuretic hormone (SIADH) or diabetes insipidus (DI), which are related conditions. However, the client in option 2, with the imbalance in fluid balance, requires immediate attention to prevent further complications.
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