The nurse is caring for a client diagnosed with diabetes insipidus (DI). Which intervention should be implemented? 1. Administer sliding-scale insulin as ordered. 2. Restrict caffeinated beverages. 3. Check urine ketones if blood glucose is >250. 4. Assess tissue turgor every four (4) hours.
The correct intervention that should be implemented for a client diagnosed with diabetes insipidus (DI) is option 4: Assess tissue turgor every four (4) hours
The correct intervention that should be implemented for a client diagnosed with diabetes insipidus (DI) is option 4: Assess tissue turgor every four (4) hours.
Diabetes insipidus is a condition characterized by the inability of the body to regulate water balance. It is not related to glucose metabolism like diabetes mellitus. As a result, the client with DI experiences excessive thirst and frequent urination, leading to dehydration.
Assessing tissue turgor is an essential nursing intervention for clients with DI to monitor their hydration status. Tissue turgor refers to the elasticity and resilience of the skin. When a person is dehydrated, their skin loses elasticity and doesn’t bounce back quickly after being gently pinched. Checking tissue turgor every four (4) hours allows the nurse to identify signs of dehydration promptly and intervene accordingly.
Administering sliding-scale insulin (option 1) is not appropriate for DI because this condition does not involve abnormalities in glucose regulation. Insulin is used to manage diabetes mellitus, which is characterized by high blood glucose levels.
Restricting caffeinated beverages (option 2) may be a general recommendation for clients with various conditions, including diabetes mellitus. However, in DI, the primary concern is excessive water loss and dehydration, rather than caffeine intake. Adequate fluid intake is essential to manage DI, unless specifically contraindicated for other reasons.
Checking urine ketones if blood glucose is >250 (option 3) is also not necessary for DI. The presence of ketones in the urine indicates a breakdown of fatty acids for energy, which is characteristic of diabetes mellitus when blood glucose levels are high. Since DI does not involve glucose metabolism abnormalities, checking urine ketones is not related to the care of these clients.
In summary, the most appropriate intervention for a client diagnosed with DI is to assess tissue turgor every four (4) hours to monitor hydration status and identify signs of dehydration.
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