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 professional shared governance is not a patient care action, but an organizational model that empowers nurses and other health care professionals to participate in decision making and policy development within their practice settings¹.
Choice B reason: This is an incorrect choice because nursing care delivery model is not a patient care action, but a framework that defines how nursing care is organized, coordinated, and delivered to the patients. Examples of nursing care delivery models include primary nursing, team nursing, and case management².
Choice C reason: This is the correct choice because interprofessional communication is a patient care action that involves exchanging information, ideas, and feedback among health care professionals from different disciplines who work together to provide comprehensive care for the patients. Interprofessional communication enhances collaboration, quality, and safety of care³.
Choice D reason: This is an incorrect choice because continuing staff education is not a patient care action, but a professional development activity that involves updating and enhancing the knowledge and skills of the health care staff through formal or informal learning opportunities. Continuing staff education improves the competence and performance of the staff.
Correct Answer is D
Explanation
Choice A reason: This is incorrect. Wiping up the liquid with paper towels and gloves can spread the mercury droplets and increase the risk of exposure. Mercury can also penetrate through nitrile gloves and cause skin irritation.
Choice B reason: This is incorrect. Disinfecting the area with chlorine bleach can create toxic vapours that can harm the respiratory system. Chlorine bleach is not effective in removing mercury from the surface.
Choice C reason: This is incorrect. Contacting the housekeeping staff to mop up the liquid can delay the proper clean-up and disposal of mercury. Mopping can also disperse the mercury droplets and contaminate the mop and the water.
Choice D reason: This is correct. Consulting the agency’s materials safety data sheets (MSDS) is the priority action of the nurse. MSDS provide information on the hazards, precautions, and procedures for handling and disposing of mercury. The nurse should follow the MSDS guidelines and use the appropriate equipment and methods to clean up the spill.
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