The nurse is admitting a patient with severe dehydration. Assessment data reveal a decreased blood pressure, an increased pulse rate, and a low circulating blood volume
The student observes that the patient is confused and restless. Which patient information would the nurse consider as a contributing factor when choosing the nursing diagnostic label?
a.
Blood pressure, pulse rate
b.
Blood pressure, pulse rate, blood volume
c.
Blood pressure, pulse rate, blood volume, mental status
d.
Blood pressure, pulse rate, blood volume, mental status, dehydration
ANS: D
All patient information should be considered as potentially contributing to the identification of diagnostic labels. This information includes subjective and objective data collected through physical assessment of the patient, interview of the patient and family members, and laboratory and diagnostic test results, including x-rays, physicians' orders, and documentation from health care providers. Verifying specific nursing diagnoses for a particular patient or situation follows accurate analysis and clustering of data.
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