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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

GERD can increase the risk of aspiration (inhalation of stomach contents into the lungs), which can cause respiratory issues, including abnormal breath sounds. In these cases, monitoring of breath sounds may be more appropriate than monitoring of bowel sounds.

Bowel sounds are not typically monitored for GERD patients as GERD is a condition that aﬀects the esophagus and the stomach, not the intestines. GERD is caused by the reﬂux of stomach contents into the esophagus, which can cause symptoms such as heartburn and regurgitation.

Abdominal girth is not routinely monitored for GERD patients as it is not typically related to the condition. GERD is a disorder that aﬀects the esophagus and stomach and does not typically cause significant changes in abdominal size or girth. In rare cases, GERD can be complicated by a condition known as a para oesophageal hernia, which can cause a visible bulge in the abdomen. In these cases, monitoring of abdominal size and shape may be necessary.

The apical pulse is not routinely monitored for GERD patients as it is not directly related to the condition. GERD is a disorder that aﬀects the digestive system, specifically the esophagus and stomach and does not typically have an impact on heart rate or rhythm.

A. frequency of nonsteroidal anti-inﬂammatory drug (NSAID) use. B. family history of gastric problems. C. recent weight gain or loss. D. amount of fat in the diet.

Correct Answer is A

Explanation

NSAIDs are known to be a common cause of acute gastritis. Therefore, it is essential for the nurse to ask the patient about their frequency of NSAID use to determine if this may have caused their current symptoms. Other options such as family history of gastric problems, recent weight gain or loss, and amount of fat in the diet, may also be relevant to the patient's overall health status, but they are not as important as the potential cause of their current condition.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When admitting a patient with a stroke who is unconscious and unresponsive to stimuli. The nurse learns from the patient’s family that the patient has a history of GERD, the nurse will plan to do frequent assessment of the patient’s:

Correct Answer is A

Explanation

The nurse is admitting a patient who is nauseated and vomiting up blood-streaked ﬂuid with diagnosis of acute gastritis. When obtaining the admission health history, it will be most important for the nurse to ask the patient about:

Correct Answer is A

Explanation

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