A patient is admitted with copious diarrhe
a. The patient is dizzy when standing, and skin assessment reveals abrasions around the perianal area. What assessment finding demonstrates that goals for the priority nursing diagnosis have been met?
a. Perianal skin abrasions are smaller in size.
b. Patient does not fall while hospitalized.
c. Patient sits up without dizziness.
d. Patient is able to tolerate oral fluids.
D
The priority diagnosis for this patient is decreased cardiac output or fluid volume deficit, either of which is evaluated with the lack of dizziness. Falling indicates dehydration or weakness, both brought about by the cardiac output situation. Skin integrity is important but not the priority. Be-ing able to tolerate fluids indicates treatment is going well. However, the priority diagnosis re-lates to cardiac output and fluid volume.
You might also like to view...
A patient has inability to clear thick secretions from her airway. Which nursing interventions are appropriate to address this problem?
1. Encourage bedrest to conserve energy. 2. Administer pain medications as needed. 3. Position the patient on the unaffected side. 4. Encourage the patient to provide as much self-care as possible. 5. Encourage slow, deep breaths.
The nurse is working with male teens whose partners are pregnant. What situation requires that the nurse intervene? The father-to-be states that:
1. He is the only other person who will be present, although his girlfriend wants her mother to be with her during the birth. 2. He is not convinced that he is the father of the baby and doesn't want his name on the birth certificate. 3. The pregnancy doesn't seem real to him, and he's not sure what he should do to plan for the future. 4. Because his father was not involved in his life, he wants to be actively involved in the life of his child.
Which of the following is a clinical indication for the use of nonsteroidal anti-inflammatory drugs (NSAIDs)?
A. Chronic treatment of dysmenorrhea B. Relief of mild to moderate pain where opioids are not indicated or warranted C. Control of the signs and symptoms of osteoarthritis and rheumatoid arthritis D. All of the above
Identify an accurate statement about Parkinson's disease.
A. Parkinson's disease is caused by the destruction of the acetylcholine neurons. B. Parkinson's disease may eventually result in physical disability. C. Parkinson's disease is treated primarily by psychotherapy. D. Parkinson's disease is caused by the degradation of the corpus striatum.