The unlicensed assistive personnel (UAP) complains to the nurse she has filled the water pitcher four (4) times during the shift for a client diagnosed with a closed head injury and the client has asked for the pitcher to be filled again. Which intervention should the nurse implement first? 1. Tell the UAP to fill the pitcher with ice cold water. 2. Instruct the UAP to start measuring the client’s I & O. 3. Assess the client for polyuria and polydipsia. 4. Check the client’s BUN and creatinine levels.
In this situation, the UAP has complained about refilling the water pitcher multiple times for a client diagnosed with a closed head injury
In this situation, the UAP has complained about refilling the water pitcher multiple times for a client diagnosed with a closed head injury. The client has requested for the pitcher to be filled again. The nurse needs to prioritize and decide on the most appropriate intervention to address the situation effectively.
To choose the correct intervention, it is important to understand the reasoning behind each option:
1. Tell the UAP to fill the pitcher with ice-cold water: This option focuses on the temperature of the water and does not address the underlying concern of the client repeatedly requesting water.
2. Instruct the UAP to start measuring the client’s I&O (intake and output): This option is more relevant as it involves monitoring the client’s fluid intake and output. However, it might not be the best initial intervention.
3. Assess the client for polyuria and polydipsia: This option involves assessing the client for excessive urination (polyuria) and excessive thirst (polydipsia). Since the client is consistently requesting water, assessing for these symptoms can help determine if there is an underlying issue causing the increased need for fluids.
4. Check the client’s BUN and creatinine levels: This option involves measuring the client’s blood urea nitrogen (BUN) and creatinine levels. Elevated levels of BUN and creatinine can indicate kidney dysfunction, which might be related to the increased water intake.
Considering all the options, the nurse should implement intervention number 3, assess the client for polyuria and polydipsia, as the first step. This intervention targets understanding the underlying cause of the client’s increased need for water. By assessing for excessive urination and excessive thirst, the nurse can gather important information about the client’s condition and determine if any further interventions or assessments are required.
Once the assessment is completed, the nurse can decide on the subsequent steps, such as instructing the UAP to measure the client’s I&O or checking the client’s BUN and creatinine levels, based on the findings of the assessment.
It is important to note that this response is based on the information provided. In an actual clinical setting, the nurse should consult a healthcare professional or follow their institution’s protocols for the specific management of clients with closed head injuries.
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