A client has received morphine for reports of pain at a recent surgical incision site. After receiving the medication, the client starts picking at the bedsheets and saying, "Get the bugs off my bed, I can feel them crawling on me!"
Which nursing diagnosis is appropriate for this client?
A) Disturbed Sensory Perception: Kinesthetic related to side effects of medication as evidenced by client statement of "Get the bugs off my bed, I can feel them crawling on me."
B) Disturbed Sensory Perception: Tactile as evidenced by client statement of "Get the bugs off my bed, I can feel them crawling on me."
C) Disturbed Sensory Perception related to client statement of "Get the bugs off my bed, I can feel them crawling on me."
D) Disturbed Sensory Perception: Tactile related to side effects of medication as evidence by client statement of "Get the bugs off my bed, I can feel them crawling on me."
Ans: D
Feedback:
The correctly written nursing diagnosis is Disturbed Sensory Perception: Tactile related to side effects of medication as evidence by client statement of "Get the bugs off my bed, I can feel them crawling on me." Since the nursing diagnosis is not a "risk for" diagnosis, it must have a "related to" and "as evidenced by" statement.
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