Which nursing diagnosis is most appropriate for a patient with xerostomia?

Total urinary incontinence related to inability to feel urge to urinate

Impaired oral mucous membranes related to decreased salivation and dry mouth

Bathing self-care deficit related to inability to perceive left-sided body parts

Disturbed sensory perception related to feeling of electric pain in feet and hands

Answer and Explanation

The Correct Answer is B

Choice A reason: This is incorrect. Total urinary incontinence related to inability to feel urge to urinate is not appropriate for a patient with xerostomia. Xerostomia is the condition of having a dry mouth due to reduced or absent saliva production. It does not affect the urinary system or the sensation of bladder fullness.

Choice B reason: This is correct. Impaired oral mucous membranes related to decreased salivation and dry mouth is appropriate for a patient with xerostomia. Xerostomia can cause oral mucous membranes to become dry, cracked, inflamed, or infected. It can also affect the patient's ability to chew, swallow, speak, or taste.

Choice C reason: This is incorrect. Bathing self-care deficit related to inability to perceive left-sided body parts is not appropriate for a patient with xerostomia. Xerostomia does not affect the patient's perception of body parts or the ability to perform bathing activities.

Choice D reason: This is incorrect. Disturbed sensory perception related to feeling of electric pain in feet and hands is not appropriate for a patient with xerostomia. Xerostomia does not cause electric pain in the extremities. This symptom may be related to a nerve disorder, such as peripheral neuropathy.

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Correct Answer is B

Explanation

Choice A reason: This is incorrect. The patient frequently using an alcohol-based sanitizer for hand hygiene does not pose a risk for poisoning. Alcohol-based sanitizers are safe and effective for reducing the transmission of germs.

Choice B reason: This is correct. The patient taking acetaminophen 1000 mg every 4 hours around the clock poses a risk for poisoning. Acetaminophen is a common over-the-counter pain reliever that can cause liver damage or failure if taken in excess or for a prolonged period of time. The maximum daily dose of acetaminophen for adults is 4000 mg.

Choice C reason: This is incorrect. The patient taking alprazolam 0.25 mg every 8 hours does not pose a risk for poisoning. Alprazolam is a prescription medication that belongs to the benzodiazepine class of drugs. It is used to treat anxiety and panic disorders. It can cause side effects such as drowsiness, dizziness, or dependence, but not poisoning.

Choice D reason: This is incorrect. The patient rinsing with a fluoride mouthwash after brushing the teeth does not pose a risk for poisoning. Fluoride is a mineral that helps prevent tooth decay and strengthen the enamel. It is added to many dental products and public water supplies. It can cause mild stomach upset if swallowed in large amounts, but not poisoning.

A. Utilize a no-rinse shampoo cap. B. Use a handheld shower sprayer. C. Have the patient lean over the wash basin. D. Have the patient lean back into the sink.

Correct Answer is A

Explanation

Choice A reason: This is the correct choice because utilizing a no-rinse shampoo cap is the best option for washing the patient’s hair who has just undergone shoulder replacement surgery. A no-rinse shampoo cap is a disposable cap that contains a pre-moistened shampoo and conditioner. It can be heated in a microwave and applied to the patient's head without the need for water or rinsing. It can clean and condition the patient's hair without causing any discomfort or movement of the affected shoulder.

Choice B reason: This is an incorrect choice because using a handheld shower sprayer is not the best option for washing the patient’s hair who has just undergone shoulder replacement surgery. A handheld shower sprayer is a device that attaches to a faucet and allows the user to direct the water flow. It can be difficult and painful for the patient to use or hold the sprayer with the affected shoulder, and it can also wet the surgical dressing or incision site.

Choice C reason: This is an incorrect choice because having the patient lean over the wash basin is not the best option for washing the patient’s hair who has just undergone shoulder replacement surgery. A wash basin is a bowl or sink that contains water and soap for washing. It can be uncomfortable and risky for the patient to lean over the basin with the affected shoulder, and it can also wet the surgical dressing or incision site.

Choice D reason: This is an incorrect choice because having the patient lean back into the sink is not the best option for washing the patient’s hair who has just undergone shoulder replacement surgery. A sink is a basin with a faucet that provides water for washing. It can be uncomfortable and risky for the patient to lean back into the sink with the affected shoulder, and it can also wet the surgical dressing or incision site.

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Which nursing diagnosis is most appropriate for a patient with xerostomia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment finding leads the nurse to add risk for poisoning to the patient’s care plan?

Correct Answer is B

Explanation

Which is the best option for washing the patient’s hair who has just undergone shoulder replacement surgery?

Correct Answer is A

Explanation

The nurse is having difficulty hearing his patient’s apical pulse with his stethoscope. Which action will help the nurse hear the heartbeat more clearly?

The nurse is caring for a patient who took 60 acetaminophen tablets. Which resource will the nurse contact for treatment guidelines when the patient arrives in the emergency room?

Which instruction will the nurse give to the patient about proper use of patient-controlled analgesia (PCA)?

Which is the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea?

Which type of error is it when the wrong type of medication is administered to the patient?

Once a week, staff members from all the disciplines caring for the trauma patients get together to discuss their progress. Which term best describes this patient care action?

Which nursing diagnosis is most appropriate for a patient with xerostomia?

Which is an example of nociceptive pain?