Answer to Question 1
Answer: B
The client is in a new environment. Changes in environment bring about uncertainty, and the client may be unable to sleep or may sleep less well than at home. Although the client is confused, there is no other data presented on a possible cause, making Disturbed Sleep Pattern a more appropriate selection than Disturbed Sensory Perception. In addition, Disturbed Sensory Perception relates to one of the five senses. Ineffective Health Maintenance and Ineffective Coping are more global and not applicable to this client's situation.
Answer to Question 2
Answer: C
Urinary output is normally equivalent to the amount of fluids ingested; the usual range is 1,500-2,000 mL in 24 hours, or 40-80 mL in 1 hour (0.5 mL/kg per hour). Clients whose intake substantially exceeds output are at risk for fluid volume excess; however, the client is dehydrated. The extra fluid intake is being used to improve body fluid balance. The client's output is 40 mL/hr, which is within the normal range. A diuretic is not needed because the client is being treated for dehydration. Treatment has been effective; however, it should continue until the intake and output are more balanced. Ending treatment now could further jeopardize this client's fluid balance.
The tone of the nurse-patient introduction sets the stage for the patient interview and patient care
A parish nurse checks the blood pressure of a church member
Perform Adult Rescue Breathing and One-Rescuer or Two-Rescuer CPR
An oral contraceptive showing the daily doses and the different formulation taken in the last 7 days ...
After 159 days,she paid a maturity value of $11,626, which included interest of $814.