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
The peak time of 70/30 NPH/regular insulin premix is usually 2 to 12 hours after injection, with an average peak time of 4 to 6 hours. This means that the highest risk of hypoglycemia is typically 4 to 6 hours after the injection, which would fall between 11:00 AM and 1:00 PM. However, it's important to note that hypoglycemic reactions can occur at any time, so the client should be monitored closely throughout the day for any signs or symptoms of low blood sugar.
Correct Answer is C
Explanation
The operating room is a sterile environment, and it is critical to maintain a clean and controlled environment to reduce the risk of infection to the patient. The measures taken include maintaining positive air pressure, controlling temperature and humidity, filtering the air, using sterile surgical instruments, and limiting traffic in and out of the operating room. These measures help to prevent the spread of infectious agents that may be present in the operating room. While the other options (a, b, and d) may also be important considerations in the design of the operating room, preventing transmission of infection is the primary goal.
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