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 A
Explanation
Clients with acute gastritis are recommended to eat smaller, frequent meals instead of three large meals. This helps to reduce the workload on the digestive system and allows the stomach to heal. Therefore, option A is not a suitable nursing intervention for a client with acute gastritis.
Options b, c, and d are all appropriate nursing interventions for a client with acute gastritis. Observing stool characteristics can help to identify any bleeding or inflammation in the gastrointestinal tract, evaluating intake and output can help to identify any fluid imbalances, and monitoring laboratory reports of electrolytes can help to identify any imbalances that may occur because of vomiting or diarrhea.
Correct Answer is A
Explanation
The nurse will include the instruction "Offer the client the commode or urinal every 2 hours" in the teaching plan for the client's family. This approach is known as timed voiding and can help the client re-establish a regular pattern of urination. Option "a" promotes frequent voiding, which helps
prevent accidents and promotes bladder health. Option "b" is not a recommended approach and can lead to dehydration, urinary tract infections, and other complications. Option "c" is also not recommended since holding urine for extended periods can lead to bladder distention and increase the risk of urinary tract infections. Option "d" is also not recommended since catheterization should only be considered in specific cases where other options have failed or are not feasible.
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