A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. After analyzing these data, the nurse assigns which of the following nursing diagnoses?
a. Adult failure to thrive
b. Hypothermia
c. Deficient fluid volume
d. Nausea
C
The signs the patient is exhibiting are consistent with dehydration. Even without knowing the clinical manifestations of dehydration, the question can be answered by the process of elimination. Adult failure to thrive, hypothermia, and nausea are not appropriate diagnoses because data are insufficient to support these diagnoses.
You might also like to view...
The nurse assesses indications that the recovering alcoholic may be developing Wernicke's encephalopathy when the nurse observes: (Select all that apply.)
a. confusion. b. hallucinations. c. verbally aggressive behavior. d. ataxia. e. seizures.
The nurse discusses fetal development and states that the hormone responsible for suppressing the maternal immunologic response to the fetus thereby facilitating physiological acceptance of the pregnancy is:
A) Progesterone B) Estrogen C) Human placental lactogen D) Human chorionic gonadotropin
Which statement best demonstrates the understanding of appropriate nurse delegation in today's healthcare environment?
A) "This is my first shift with this team. How was the care delegated yesterday?" B) "We are working with fewer team members today. Who has experience with chest tubes?" C) "Our clients are really high acuity. We will really need to work as an effective team today." D) "As team leader, come to me if you feel you need help or are unclear with what you need to do."
Which of the following is a major reason behind the continued increase in the incidence of tuberculosis? (Select all that apply.)
a. Concern over privacy means that many cases of infection are not identified. b. Infectious agents are becoming drug-resistant and are not as susceptible to treatment. c. Many persons are unwilling to name their contacts to public health nurses. d. People are becoming very complacent about practicing good hygiene. e. The environment in the United States is becoming increasingly dangerous. f. Infected persons are not always compliant with the long, costly treatment regimen.