The nurse is caring for a client with ulcerative colitis and severe diarrhea. Which nursing assessment is the highest priority?
a. Skin integrity
b. Blood pressure
c. Heart rate and rhythm
d. Abdominal percussion
C
Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Abdominal percussion is an important part of physical assessment but has lower priority for this client than heart rate and rhythm.
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A) True B) False
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Interpretation of comfortable personal space is the same for all people.
Answer the following statement true (T) or false (F)
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