Ricky, age 18, is admitted with a decreased level of consciousness secondary to a closed head injury resulting from a fall while roller-skating. His urine output is 500cc from 6 AM to 11 AM, 1,000cc from 11 AM to 2 PM, and 350cc from 2 PM to 3 PM. Which of the following actions by the nurse is appropriate?
A)Realize that this is normal urine output and continue to monitor Ricky
B)Encourage Ricky to drink 8 to 10 glasses of fluid daily
C)Check the urine specific gravity and report any abnormality as well as the urine output
D)Decrease the IV rate from 100cc/hr to 25cc/hr, suspecting fluid excess

Question

Quizplus · Accepted Answer

Check the urine specific gravity and report any abnormality, as well as the urine output. Since the urine output of the client is excessive (i.e., 350cc/hr or more), this marks a classic sign of Diabetes insipidus (DI). Diabetes insipidus can develop with head injury, tumors, and other conditions that cause increased intracranial pressure. The specific gravity provides valuable information about renal function and response to antidiuretic hormone (ADH).

Ricky, Age 18, Is Admitted with a Decreased Level of Consciousness