The nurse identifies the following priority nursing diagnosis for an elderly client experiencing diarrhea:
A)
Risk for Fluid Volume Excess related to diarrhea.
B)
Potential for Impaired Skin Integrity related to diarrhea.
C)
Risk for Imbalanced Nutrition less than Body Requirements related to diarrhea.
D)
Risk for Dehydration related to diarrhea.
D
Explanation:
A)
The elderly become dehydrated quickly from loss of fluids and electrolytes, possibly leading to hypovolemic shock and metabolic acidosis. A fluid volume deficit, not excess would occur. Options B and C are also a concern, but not of highest priority.
Analysis
Planning
Safe, Effective Care Environment: Coordinated Care
B)
The elderly become dehydrated quickly from loss of fluids and electrolytes, possibly leading to hypovolemic shock and metabolic acidosis. A fluid volume deficit, not excess would occur. Options B and C are also a concern, but not of highest priority.
Analysis
Planning
Safe, Effective Care Environment: Coordinated Care
C)
The elderly become dehydrated quickly from loss of fluids and electrolytes, possibly leading to hypovolemic shock and metabolic acidosis. A fluid volume deficit, not excess would occur. Options B and C are also a concern, but not of highest priority.
Analysis
Planning
Safe, Effective Care Environment: Coordinated Care
D)
The elderly become dehydrated quickly from loss of fluids and electrolytes, possibly leading to hypovolemic shock and metabolic acidosis. A fluid volume deficit, not excess would occur. Options B and C are also a concern, but not of highest priority.
Analysis
Planning
Safe, Effective Care Environment: Coordinated Care
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Which of the following services are typically performed by psychiatric nurses employed in managed care organizations? Standard Text: Select all that apply
1. Performing mental health assessments 2. Scheduling appointments for therapy 3. Providing stress management classes 4. Contacting medication prescribers to arrange for changes 5. Triaging initial requests for services
The client has been brought via ambulance to the emergency department (ED) following a motor vehicle accident. The nurse notes that the client's ear is draining clear fluid. Which is the priority nursing action?
1. Requesting information from the client regarding any chronic allergies. 2. Testing the drainage for glucose. 3. Asking the client if there have been recent middle ear infections. 4. Irrigating the ear with warm mineral oil or peroxide, and flushing with warm water.
A pregnant 15-year-old girl presents to the emergency department (ED) of the local private hospital. She has been transported by her mother and appears to be in active labor
The girl is crying uncontrollably and says she is scared and experiencing painful contractions. Her mother states, "We don't have any money or insurance, but this hospital is closer than the public hospital, and she needs help now." What is the first step that the ED staff should take? a. Arrange for an ambulance to transport her to the nearest public hospital. b. Explain to the girl and her mother that the hospital only accepts patients who can pay the hospital bill. c. Examine her to determine whether her condition is stable or whether she requires immediate medical attention. d. Inform her mother that she will need to transport her daughter to the nearest public hospital.
The client is an older woman having an excisional biopsy performed on a 4-mm lesion on the back of her neck, which will be closed with one or two sutures. She asks if she can go to her card party tonight. What is your best response?
A. "Yes, just keep the dressing on until tomorrow." B. "Yes, as long as no one there has a cold or other infection." C. "No, you must remain still to prevent excessive bleeding from the incision." D. "No, you will not have recovered sufficiently from the anesthesia to go out this evening."