The nurse is creating the care plan for a patient with symptoms of DI who was admited to the hospital for evaluation and treatment of the condition. An appropriate nursing diagnosis for the patient is:
Excess fluid volume related to intake greater than output.
Risk for impaired skin integrity related to generalized edema.
Activity intolerance related to muscle cramps and weakness.
Insomnia related to waking at night to void.
The Correct Answer is A
Excess fluid volume related to intake greater than output would be the most appropriate nursing diagnosis for a patient with symptoms of DI (diabetes insipidus). This condition results in excessive urine output and, as a consequence, can lead to dehydration and electrolyte imbalances. Therefore, monitoring and managing fluid volume is a priority for patients with DI.
Risk for impaired skin integrity related to generalized edema is more commonly associated with conditions that cause fluid retention such as heart failure, liver failure, or kidney disease, rather than DI.
Activity intolerance related to muscle cramps and weakness is a possible nursing diagnosis for patients with conditions that affect muscle function, such as muscular dystrophy or multiple sclerosis, but not specifically for DI.
Insomnia related to waking at night to void is more commonly associated with urinary frequency or nocturia due to conditions such as urinary tract infections or benign prostatic hyperplasia, but not specifically for DI.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choicec. The cobalamin injections will prevent me from becoming anemic.
Choice A rationale:
Cobalamin (B12) injections do not increase hydrochloric acid production in the stomach.Chronic atrophic gastritis often leads to decreased production of hydrochloric acid due to the loss of parietal cells, but B12 injections do not reverse this condition.
Choice B rationale:
The need for cobalamin injections is typically lifelong in patients with chronic atrophic gastritis because the condition leads to a permanent loss of intrinsic factor, which is necessary for B12 absorption. The injections are not just until the stomach heals.
Choice C rationale:
Chronic atrophic gastritis can lead to vitamin B12 deficiency due to the loss of intrinsic factor, which is essential for B12 absorption.This deficiency can cause pernicious anemia, and B12 injections are necessary to prevent this condition.
Choice D rationale:
While chronic atrophic gastritis does increase the risk of stomach cancer, B12 injections are not specifically aimed at reducing this risk.The primary purpose of B12 injections is to prevent anemia.
Correct Answer is C
Explanation
The nurse should act on the order to insert a 16 French retention catheter first. The patient's markedly distended bladder and agitated and confused state suggest acute urinary retention, which can be relieved by inserting a catheter to drain the urine. This is a priority intervention as urinary retention can lead to serious complications such as bladder rupture, hydronephrosis, and renal failure. Once the catheter is inserted and the patient's bladder is drained, the healthcare provider can order further tests such as an IVP or blood tests to assess renal function. The order for lorazepam can be addressed after the catheter is inserted and the patient's urinary retention is addressed.
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