A client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is?

1. A

   Measure the urinary output

2. B

   Check the vital signs

3. C

   Encourage increased fluid intake

4. D

   Weigh the client

Appeared in: DHS 2018 shift 1st

Explanation

• Mental confusion in a client with Diabetes Insipidus is a critical sign of severe dehydration and high sodium levels (hypernatremia), indicating poor blood flow to the brain.
• This level of dehydration can quickly lead to hypovolemic shock, a life-threatening condition where the heart cannot pump enough blood to the body.
• The nursing priority is to use the ABCs (Airway, Breathing, Circulation) framework. Mental confusion points to a 'Circulation' problem.
• Checking vital signs (blood pressure, heart rate) is the fastest and most direct way to assess for hemodynamic instability (e.g., low blood pressure, fast heart rate) and the risk of shock.

Why Other Options Were Wrong

• Option A: Measuring urinary output is an important monitoring task to quantify fluid loss, but it does not assess the immediate life-threatening risk of circulatory collapse.
• Option C: This is unsafe. A client with mental confusion has an altered level of consciousness and a diminished gag reflex, which creates a high risk of choking and aspirating fluid into the lungs.
• Option D: While daily weight is the most accurate long-term indicator of fluid balance, it is not the priority in an acute crisis. It does not provide immediate data about hemodynamic stability.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Prioritization of nursing interventions for complications of Diabetes Insipidus to guide bedside assessment, documentation, and the next nursing action.
• In any patient with a condition causing significant fluid loss, a change in mental status is a red flag for severe dehydration and requires immediate assessment of the ABCs (Airway, Breathing, Circulation).
• Prioritizing vital signs allows the nurse to quickly identify and report signs of shock, enabling rapid intervention with IV fluids and medications to prevent cardiovascular collapse and death.
• What if? If the client was alert and oriented but reported increased thirst and urination, the priority would shift. In that stable scenario, measuring intake and output and notifying the provider would be the priority to guide fluid replacement and medication adjustment.

How to Approach the Question

• First, identify the patient's underlying condition from the history: Diabetes Insipidus (DI), a disorder of water balance.
• Second, recognize the critical cue in the stem: 'mental confusion'. This is not a typical symptom of simple DI; it's a sign of a severe complication.
• Third, apply a prioritization framework like the ABCs (Airway, Breathing, Circulation). Mental confusion suggests a problem with cerebral perfusion, which falls under 'Circulation'.
• Fourth, evaluate the options based on this priority. 'Check the vital signs' is a direct and rapid assessment of circulatory status (blood pressure, heart rate).
• Finally, eliminate the other options by assessing their immediacy and safety. Measuring output and weighing are monitoring tasks, not immediate assessments of stability. Encouraging fluids is unsafe in a confused patient.

Concept Tested & Keywords

• Concept Tested: Prioritization of nursing interventions for complications of Diabetes Insipidus.
• Stem keywords: diabetes insipidus, polyuria, polydipsia, mental confusion, priority intervention
• Lead-in keywords: priority
• Clinical cues: Mental confusion: Indicates severe dehydration affecting cerebral perfusion, a late and serious sign.

Question ID

QMkggSJ5IqluvH66a5vgqV

Copy ID

Reference Book

E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 61-63

E6 Nursing Brunner Adult Health 3SA Vol 1 Part 1 p. 143-145