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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is an incorrect choice because powerlessness related to inability to keep from eating during sleep is not the highest priority nursing diagnosis for a patient who developed sleep-related eating disorder when taking Zolpidem. Powerlessness is a psychosocial problem that affects the patient's sense of control and self-efficacy. However, it is not the most urgent or life-threatening problem for the patient, as it does not pose an immediate risk of harm or injury.
Choice B reason: This is an incorrect choice because wandering related to cognitive impairment from sleeping aid is not the highest priority nursing diagnosis for a patient who developed sleep-related eating disorder when taking Zolpidem. Wandering is a behavioral problem that involves moving about aimlessly or without purpose. However, it is not the most urgent or life-threatening problem for the patient, as it does not necessarily imply a risk of harm or injury.
Choice C reason: This is the correct choice because risk for falls related to ambulating to kitchen while asleep is the highest priority nursing diagnosis for a patient who developed sleep-related eating disorder when taking Zolpidem. Risk for falls is a safety problem that involves an increased likelihood of falling due to factors such as impaired balance, coordination, or judgment. This is the most urgent and life-threatening problem for the patient, as it can result in serious injuries or complications.
Choice D reason: This is an incorrect choice because risk for imbalanced nutrition: more than body requirements related to sleep eating is not the highest priority nursing diagnosis for a patient who developed sleep-related eating disorder when taking Zolpidem. Risk for imbalanced nutrition: more than body requirements is a physiological problem that involves an intake of nutrients that exceeds metabolic needs. However, it is not the most urgent or life-threatening problem for the patient, as it does not cause an immediate risk of harm or injury.
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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