Author Question: You are working with a client who is in the manic phase and having difficulty sleeping, with only 0 ... (Read 54 times)

imanialler · **on:** Jul 19, 2018

You are working with a client who is in the manic phase and having difficulty sleeping, with only 0 to 2 hours of sleep recorded by the night shift nurse.

Which of the following would you write as a nursing diagnosis using North American Nursing Diagnosis Association (NANDA) classifications? a. difficulty sleeping, manic related, evidenced by complaint of problems sleeping
b. loss of sleep, sensory related, evidenced by staying up most of the night according to staff
c. sleep pattern disturbance, related to sensory alterations, evidenced by sleep record (0 to 2 hours per night)
d. sensory overload, biochemically related, evidenced by lack of sleep

Question 2

A person begins to experience auditory hallucinations and paranoid delusional thinking during freshman year in college. The person is unable to pass the semester's courses and has to withdraw from the college.

A nurse applying Margaret Newman's Theory of Health as Expanding Consciousness would describe this person as having reached a: a. self-care deficit
b. choice point
c. culture shock
d. line of resistance

katheyjon · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

C
The most appropriate NANDA classification would be, Sleep pattern disturbance, related to sensory alterations, evidenced by sleep record (0 to 2 hours per night). This particular diagnosis contains all three parts needed for a NANDA diagnosis. The parts include the problem, what the problem is related to, and how the problem is demonstrated. The other three options would not be correct for this client, according to NANDA.

Answer to Question 2

B
According to Newman, when a person's patterns have been disrupted and activities that had been successful in the past are not effective in handling the disruption, the person has reached a choice point. In the situation presented, the student's experience of hallucinations and delusional thinking is interfering with performing effectively. The student makes the choice to withdraw from college.