The nurse is caring for an adult client who was admitted to the ...

[cnetterville]

The nurse is caring for an adult client who was admitted to the hospital 3 days ago. The client is having a hard time sleeping.
 
  The nurse notes that there is documentation of some confusion during waking hours. Based on this data, which nursing diagnosis is the most appropriate?
  A) Ineffective Coping
  B) Disturbed Sleep Pattern
  C) Disturbed Sensory Perception
  D) Ineffective Health Maintenance

Question 2

The nurse is analyzing the intake and output record for a client being treated for dehydration.
 
  The client weighs 176 lbs. and had a 24-hour intake of 2,000 mL and urine output of 1,200 mL. Based on this data, which conclusion by the nurse is the most appropriate?
  A) Treatment needs to include a diuretic.
  B) Treatment has not been effective.
  C) Treatment is effective and should continue.
  D) Treatment has been effective and should end.

[Beatricemm]

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.

[cnetterville]

Excellent

[recede]

Gracias!