The nurse is caring for an infant who is scheduled for surgery for pyloric stenosis. When planning the infant's care, which nursing diagnoses are appropriate?
Select all that apply.
A) Deficient Fluid Volume related to inadequate intake and vomiting
B) Hyperbilirubinemia related to poor liver function
C) Sleep Pattern Disturbance related to discomfort and hunger
D) Parental Anxiety related to surgery
E) Imbalanced Nutrition, less than body requirements related to inadequate intake and vomiting
Answer: A, C, D
Appropriate nursing diagnoses to include in the infant's plan of care include deficient fluid volume due to poor intake and vomiting; sleep pattern disturbance related to the discomfort and hunger; parental anxiety related to the need for surgical correction; and imbalanced nutrition, less than body requirements due to inadequate intake and vomiting. Jaundice is not a clinical manifestation of pyloric stenosis.
You might also like to view...
A family consumed some undercooked hamburger at a picnic and has since developed bloody diarrhea. The nurse knows which of the following statements listed below is correct regarding the infectious process?
A) Evasive factors that become more virulent by evading parts of the host's immune system B) Exotoxins that damage vascular endothelium causing bleeding and low platelet counts C) Adhesion factors that can anchor a pathogen firmly to the host tissue surfaces D) Invasive factors capable of destroying the cell membrane by utilization of enzymes
An older adult who presents with complaints of insomnia, loss of energy, impaired concentration and diminished pleasure in activities she once enjoyed is showing signs of:
a. delirium b. dementia c. depression d. confusion
The nurse is preparing to apply heat to a client's leg. The therapeutic effect of heat would be to:
a. decrease inflammation and edema. c. improve blood flow to the area. b. facilitate clotting and control bleeding. d. raise the threshold of pain receptors.
During labor, a vaginal examination should be performed only when necessary because of the risk of
a. Fetal injury b. Discomfort c. Infection d. Perineal trauma