This is the first hospitalization for an adult client who, after ...

[nenivikky]

This is the first hospitalization for an adult client who, after being admitted 3 days ago, is now having trouble sleeping. The nurse also notes some confusion during waking hours.
 
  Which of the following would be the most appropriate nursing diagnosis for this client? 1. Ineffective Health Maintenance
   2. Ineffective Coping
   3. Disturbed Sensory Perception
   4. Disturbed Sleep Pattern

Question 2

The nurse planning care for a client scheduled for cataract surgery should include which of the following in the plan of care for this client?
 
  1. Resume normal activities of daily living after the procedure
   2. Limit food and fluids until fully recovered from anesthesia
   3. Avoid strenuous activity until seen by the ophthalmologist after the surgery
   4. Wear sunglasses if necessary

[vboyd24]

Answer to Question 1

4. Disturbed Sleep Pattern

Rationale: 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 that could be the cause, making Disturbed Sleep Pattern a more appropriate selection than Disturbed Sensory Perception. In addition, Disturbed sSensory 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

3. Avoid strenuous activity until seen by the ophthalmologist after the surgery

Rationale:
The client's plan of care should include instructions to avoid reading, lifting, and strenuous activity until seen by the ophthalmologist after the surgery. Client instructions should not include resuming normal activities of daily living after the procedure. Cataract removal is done as an out-patient procedure with minimal anesthesia. The client does not need to limit foods or fluids until recovered from anesthesia. Sunglasses should be worn when going outside at all times.