This nursing diagnosis applies to a patient with acute mania: Imbalanced nutrition: less than body requirements related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. Select an appropriate outcome
The patient will:
a. ask staff for assistance with feeding within 4 days.
b. drink six servings of a high-calorie, high-protein drink each day.
c. consistently sit with others for at least 30 minutes at meal time within 1 week.
d. consistently wear appropriate attire for age and sex within 1 week while on the psychiatric unit.
ANS: B
High-calorie, high-protein food supplements will provide the additional calories needed to offset the patient's extreme hyperactivity. Sitting with others or asking for assistance does not mean the patient ate or drank. The other indicator is unrelated to the nursing diagnosis.
You might also like to view...
Which client statement reflects an understanding of circadian rhythms in psychopathology?
1. "When I dream about my mother's horrible train accident, I become hysterical." 2. "I get really irritable during my menstrual cycle."3. "I'm a morning person. I get my best work done before noon." 4. "Every February, I tend to experience periods of sadness."
A patient complains of gas pains and abdominal distention two days after a small bowel resection. Which nursing action is best to take?
a. Encourage the patient to ambulate. b. Instill a mineral oil retention enema. c. Administer the ordered IV morphine sulfate. d. Offer the ordered promethazine (Phenergan) suppository.
A nurse's most appropriate initial action during the preinteraction phase of a relationship with a homosexual patient should be to:
a. examine personal feelings about homosexuality. b. review the literature that pertains to the human sexual response. c. attempt to identify the underlying reasons for the patient's values. d. focus on a method to assist the patient with changing personal sexual values.
The nurse is providing care to a preschool-age client who is diagnosed with acquired immune deficiency syndrome (AIDS). In planning the client's care, which vaccine is inappropriate for the client to receive?
1. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) 2. Haemophilus influenzae type B (HIB conjugate vaccine) 3. Varicella vaccine 4. Hepatitis B vaccine (Hep B)