The nurse is working on the pediatric floor, caring for an infant who is very fussy and has a diagnosis of DI. Which parameter should the nurse monitor while the infant is on fluid restrictions?

Correct Answer: B

Rationale: In a patient with diabetes insipidus (DI) who is on fluid restrictions, monitoring urine output is crucial to assess the effectiveness of the treatment regimen. DI is a condition characterized by excessive urination and thirst due to a deficiency of antidiuretic hormone (ADH). By monitoring urine output, the nurse can determine if the restrictions are achieving the goal of decreasing urine volume and preventing dehydration. Changes in urine output can also indicate the need for adjustments in the treatment plan. Monitoring oral intake, appearance of mucous membranes, and pulse and temperature are important aspects of pediatric care but are not as directly related to managing fluid restrictions in a patient with DI.

Correct Answer: D

Rationale: The symptoms described in the client, such as increased urination, anorexia, weakness, irritability, depression, and bone pain suggest hyperparathyroidism. In hyperparathyroidism, excess parathyroid hormone (PTH) is released, leading to increased calcium levels in the blood. This results in symptoms such as increased thirst and urination (polyuria), anorexia, weakness, irritability, depression, and bone pain. The bone pain in hyperparathyroidism can be severe and interfere with the client's ability to go outdoors. It is essential to consider hyperparathyroidism as a potential cause of these symptoms in the 68-year-old client and further diagnostic evaluations should be conducted to confirm the diagnosis.

Correct Answer: C

Rationale: During a lumbar puncture procedure, it is important to position the patient correctly to facilitate the procedure and minimize the risk of complications. Placing the patient on their side with their knees drawn up to their chest helps open up the spaces in the lower spine, making it easier for the healthcare provider to access the appropriate area for the procedure. This position also helps to minimize the risk of post-procedure complications such as spinal headaches. Monitoring the patient's vital signs is important but does not specifically relate to the nursing intervention during the lumbar puncture procedure. Labeling laboratory specimens in numerical order is also a routine task but not directly related to the procedure itself. Thus, the correct intervention during the lumbar puncture procedure is positioning the patient on their side with knees drawn up to the chest.

Correct Answer: D

Rationale: Option D, "The insulation on your nerve cells is damaged, which slows the impulses to the muscles," is the most accurate explanation for multiple sclerosis. Multiple sclerosis is a chronic autoimmune disorder where the body's immune system mistakenly attacks the myelin sheath, the protective covering of nerve fibers in the central nervous system. This damage disrupts the normal flow of electrical impulses along the nerves, leading to various symptoms such as muscle weakness, coordination problems, and balance issues. By understanding that the insulation on her nerve cells is damaged, the patient can better comprehend why she is experiencing symptoms like muscle weakness and falls.

Correct Answer: C

Rationale: These milestones are typically achieved around 24 months.