Which of the following is an appropriate nursing diagnosis for this patient?
A patient has been vomiting for 2 days and has not been able to eat or drink anything during this time. She has not urinated for 12 hours. Physical examination reveals the following: T = 99.6°F (37.6°C) orally; P = 110 beats/min, weak and thready; BP = 80/52 mm Hg. Her skin and mucous membranes are dry, and there is decreased skin turgor. The patient states that she feels very weak. The following are her laboratory results:
Sodium 138 mEq/L
Potassium 3.7 mEq/L
Calcium 9.2 mg/dL
Magnesium 1.8 mg/dL
Chloride 99 mEq/L
BUN 29 mg/dL
a. Impaired Gas Exchange related to ineffective breathing
b. Excess Fluid Volume related to limited fluid output
c. Deficient Fluid Volume related to abnormal fluid loss
d. Electrolyte Imbalance related to decreased oral intake
ANS: C
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The nurse working on an acute pediatric unit is caring for an 8-year-old child who is profoundly mentally retarded with significant developmental delays and cerebral palsy that limits the child to a wheelchair
The child was admitted for a significant scoliosis, and has had surgery to fuse the spine, with insertion of rods on both sides of the spinal column. In addition to preventing infection and pain management, the nurse's priority of care is: 1. Careful movement and repositioning of the client. 2. Supporting family coping measures. 3. Providing respite care for the primary caregiver. 4. Encouraging ambulation as soon as possible.
Height and weight measurements are essential at every health care visit for clients in all age groups because these measurements:
a. document that basic client evaluation has been done b. provide data related to maturational level c. indicate the need for diagnostic follow-up d. signal possible onset of alterations that may indicate illness
The nurse asks the patient to shrug the shoulders while the nurse applies pressure to keep the shoulders from moving. The nurse would document the results of this test as indicating strength of which muscle?
1. Sternocleidomastoid 2. Triceps 3. Biceps 4. Trapezius
Upholding a client's right to make a choice and to act on the choice involves:
a. Affirming b. Supporting c. Informing d. Decision making