A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?
High-Yield Explanation
Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce the anti-diuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration.
Option B: There’s no evidence that the client is experiencing renal failure.
Option C: Providing emollients to prevent skin breakdown is important, but doesn’t need to be performed immediately.
Option D: Slowing the rate of IV fluid would contribute to dehydration when polyuria is present.