A client is taking a diuretic that increases her urinary output.
What would be an appropriate nursing diagnosis on which to base an educational plan?
Impaired Skin Integrity.
Impaired Urinary Elimination.
Urinary Retention.
Risk for Deficient Fluid Volume.
The Correct Answer is D
Choice A rationale
Impaired Skin Integrity involves damage to the epidermal and/or dermal layers of the skin. While excessive fluid loss can indirectly affect skin turgor and increase the risk of breakdown over time, the primary and immediate physiological consequence of increased urinary output due to a diuretic is a potential reduction in overall fluid volume within the body, not a direct impairment of skin integrity.
Choice B rationale
Impaired Urinary Elimination describes difficulties in controlling or completely emptying the bladder. A diuretic, by its mechanism of action, increases urine production and thus promotes urinary elimination. While the *pattern* of elimination may change (increased frequency, urgency), the fundamental issue is not an impairment of the elimination process itself but rather an *increase* in it.
Choice C rationale
Urinary Retention is the inability to empty the bladder completely. A diuretic works to increase urine output, directly counteracting the physiological process of urinary retention. Therefore, this nursing diagnosis would be inappropriate for a client experiencing increased urinary output due to diuretic use.
Choice D rationale
Risk for Deficient Fluid Volume is a nursing diagnosis that identifies a vulnerability to a decrease in intravascular, interstitial, and/or intracellular fluid, which may compromise health. A diuretic increases urinary output, leading to a greater loss of fluid from the body. Without adequate fluid intake to compensate for this increased loss, the client is at a significant risk of developing a fluid volume deficit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A CPAP (Continuous Positive Airway Pressure) mask delivers a constant stream of pressurized air to keep the airway open during sleep, which is the primary treatment for sleep apnea. Sleep apnea is characterized by repeated pauses in breathing due to airway obstruction, and CPAP effectively prevents these episodes.
Choice B rationale
A nasal cannula delivers low-flow oxygen through two prongs inserted into the nostrils. While it can provide supplemental oxygen, it does not address the underlying airway obstruction that occurs in sleep apnea. Therefore, it is not the expected delivery device for this condition. Normal flow rate is 1 to 6 liters per minute, providing a fraction of inspired oxygen (FiO2) of 24% to 44%.
Choice C rationale
A non-rebreather mask delivers a high concentration of oxygen (60% to 90%) and is typically used for patients with acute respiratory distress. It is not the appropriate device for managing the chronic condition of sleep apnea, which primarily requires airway support rather than high oxygen levels.
Choice D rationale
A simple face mask delivers a moderate concentration of oxygen (40% to 60%) and requires a flow rate of 5 to 8 liters per minute. While it provides more oxygen than a nasal cannula, it does not address the airway obstruction inherent in sleep apnea and is therefore not the expected device for this condition.
Correct Answer is D
Explanation
Choice A rationale
While it might seem natural to inquire about prior discussions, this response could induce guilt or regret in the spouse and doesn't directly address the current emotional distress and uncertainty about the spouse's wishes as explicitly stated in the advance directive. It shifts the focus to the past rather than the present need for clarification regarding the existing directive.
Choice B rationale
Although the primary care provider may indeed have the client's best interests in mind, this statement dismisses the spouse's expressed uncertainty and relies on an assumption about the PCP's motivations. It doesn't help the spouse understand or feel confident about the content of the advance directive, which is the core of their concern.
Choice C rationale
This statement, while true, places the burden of decision-making solely on the spouse without acknowledging the existence of the advance directive, which is meant to guide such decisions. It overlooks the possibility that the directive already contains the spouse's wishes and could offer clarity, thereby increasing the spouse's anxiety.
Choice D rationale
This response directly addresses the spouse's statement by reminding them that their spouse's wishes are likely documented in the advance directive. It encourages the spouse to review the directive, which is the most direct way to understand what their spouse wanted regarding medical interventions like a PEG tube, thus providing immediate and relevant support.
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