Question

A patient is admitted for a severe head injury and develops dry mucous membranes. The urine output is 400 ml/hr for the last 8-hour shift. Prioritize the nurse's next actions.

1) Complete a neurological assessment.
2) Start IV fluids and administer nasal desmopressin (DDAVP).
3) Assess the patient's urine specific gravity and blood sodium levels.
4) Notify the physician.

a) 4, 1, 2, 3
b) 1, 4, 3, 2
c) 1, 4, 2, 3
d) 4, 3, 1, 2

Answer 1

The patient with a severe head injury and symptoms of high urine output should have a neurological assessment first, followed by notification of the physician, assessment of urine specific gravity and blood sodium levels, and then initiation of IV fluids and desmopressin if needed.

Step-by-step explanation:

The patient admitted for a severe head injury who develops dry mucous membranes and has a high urine output (400 ml/hr for the past 8-hour shift) may be experiencing a condition such as diabetes insipidus or another issue affecting the renal system or endocrine function. Prioritizing the nurse's next actions is critical to ensuring prompt and appropriate treatment.

1. Complete a neurological assessment
2. Notify the physician
3. Assess the patient's urine specific gravity and blood sodium levels
4. Start IV fluids and administer nasal desmopressin (DDAVP)

This sequence ensures that any changes in the patient's neurological status are quickly identified, the physician is made aware of the critical changes, and necessary lab tests are conducted to guide further treatment.