The nurse is admitting a 50-year-old female who was involved in a car accident whose only injuries were burns over 50% of her body. Identify the highest-priority nursing diagnosis for this client
1. Deficient Fluid Volume
2. Acute Pain
3. Disturbed Body Image
4. Coping, family, compromised
Deficient Fluid Volume
Rationale: Immediately after a burn injury, fluid begins to shift from the intracellular and intravascular compartment into the interstitial space. This is commonly referred to as "third spacing" of fluid and, if left untreated, will lead to hypovolemia and burn shock, which is life threatening. Additionally, edema develops in unburned tissues and organs distant from the site of injury when the burn size exceeds 20% of total body surface area. Acute Pain, Disturbed Body Image, and Coping, family, compromised are all important nursing diagnoses, but are not as critical as Deficient Fluid Volume at this time.
You might also like to view...
You are working with a client from another culture who states that the current illness is likely punishment for past sins. The nurse's best response to the client would be:
1. "You seem like such a nice person, what sins could cause you to deserve this?" 2. "I think you are being very hard on yourself, don't you agree?" 3. "It sounds as though you are troubled by something you did in the past." 4. "You have an infection that is caused by a virus that you came in contact with, not by sins."
When Hazel, age 65, develops herpes zoster (shingles), her physician orders Zovirax 800 mg five times a day for 10 days. Tablets of 400 mg and 800 mg are available. The ideal number and size of tablets used to fill the prescription are _______________
a. Eighty 400-mg tablets b. Ten 800-mg tablets c. Fifty 800-mg tablets d. One hundred 400-mg tablets
The most effective way for you, the charge nurse, to manage perceived conflict is to:
1. wait until the argument takes place, because you are only relying on your feelings. 2. have individual conversations with those you think sense these feelings. 3. bring everyone together in the same meeting to express feelings. 4. be aggressive in getting answers to your questions.
Nursing students are learning about assessment of the head and neck. What cultural considerations would the students learn to assess in relation to this area? (Select all that apply.)
A) Shape of the ears B) Shape of the chin C) Shape of the lips D) Shape of the nose E) Shape of the eyes