A nursing diagnosis of Risk for Deficient Fluid Volume related to excessive fluid loss, secondary to diarrhea and vomiting was implemented for a home health client who began with these symptoms 5 days ago

Question

A goal was that the client's symptoms would be eliminated within 48 hours. The client is being seen after a week, and has had no diarrhea or vomiting for the past 5 days. The nurse should:
1. Keep the problem on the care plan, in case the symptoms return.
2. Document that the problem has been resolved and discontinue the care for the problem.
3. Assume that whatever the cause was, the symptoms may return, but document that the goal was met.
4. Document that the potential problem is being prevented since the symptoms have stopped.

Answer 1

Correct Answer: 2
Rationale: In this case, the risk factors no longer exist because the causative factors have stopped. The nurse should document that the goal has been met and discontinue the care for the problem. If the problem returns, it can be implemented again and addressed at that time.