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.
Nurse bees tending to brood in cells both open and capped with beeswax.
An adult male killer whale with its characteristic tall dorsal fin swims in the waters near Tysfjord
Adult European beewolf (Philanthus triangulum) feeding on nectar
Position of hands for chest compression on an adult.
The nurse begins the general survey
The physician orders pemetrexed (Alimta) 500 mg/m2. The client’s body surface area is 2.14 ...