A client who is experiencing explosive diarrhea asks the nurse what causes the condition. The nurse responds that diarrhea can be a defense mechanism that removes:
Standard Text: Select all that apply.
1. toxins.
2. pathogens.
3. excess stool.
4. excess water.
5. excess nutrients.
Correct Answer: 1,2
Rationale 1: In some cases, diarrhea is a type of body defense, rapidly and completely ridding the body of toxins.
Rationale 2: In some cases, diarrhea is a type of body defense, rapidly and completely ridding the body of pathogens.
Rationale 3: Removing excess stool is not a body defense associated with diarrhea.
Rationale 4: Removing excess water is not a body defense associated with diarrhea.
Rationale 5: Removing excess nutrients is not a body defense associated with diarrhea.
Global Rationale: In some cases, diarrhea is a type of body defense, rapidly and completely ridding the body of toxins and pathogens. Diarrhea is not a body defense to remove too much stool, excess water, or excess nutrients.
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1. Working as a partner with the patient 2. Telling the patient they need to take more responsibility for self-care 3. Asking the patient why they make so many poor decisions 4. Working with the health care team to provide quality care
To hear a murmur best, the nurse should ask the patient to:
a. take a deep breath. b. lean forward. c. cough. d. bear down.
The caregivers of a 2 year old who has had a common cold for 4 days calls the nurse in the emergency department at 2 a.m
on a cold winter night to say that the child has awoken with a barking cough and an elevated temperature; she seems blue around her mouth. The nurse would most appropriately recommend which of the following to the caregiver? A) "Put a cool mist humidifier or vaporizer in the room to see if that relieves the cough. Call back if there's no relief in an hour." B) "Bundle the child up and take her out into the cold for a few minutes. Call back if the exposure to the cold air does not provide relief." C) "Bring the child to the emergency room immediately." D) "Turn on all of the hot water taps in the bathroom and close the door. Take the child into the steam-filled room for 15 minutes. If there is no relief, bring the child to the emergency room."
Assessment reveals that a patient has lost 10 pounds in the last 2 months. Weight loss is one of the three defining characteristics of the diagnostic category Imbalanced nutrition: less than body requirement. Knowing this, the nurse should:
A. restate the nursing diagnosis as Imbalanced nutrition: less than body requirements related to poor dietary habits. B. examine the assessment data to see if other signs and symptoms of altered nutrition exist. C. ignore the data regarding the weight loss because 10 pounds is not that much. D. restate the nursing diagnosis as Weight loss related to decreased food intake.