A child has been admitted to the hospital with acute diarrhea. Which assessment finding by the nurse would indicate that goals for the priority nursing diagnosis have been met?
A.
No stooling for 4 hours
B.
Perineal skin intact
C.
Stable weight for 2 days
D.
White blood cell count normal
ANS: C
The priority for a child with diarrhea is to maintain or restore fluid volume. Weight is the most sensitive noninvasive indicator of fluid status, and a stable weight over 2 days indicates hemodynamic stability. Alterations in skin integrity may or may not be present, but if present, they would not take priority over fluid balance. Not having a stool for 4 hours does not indicate resolution of the priority problem. WBC may be normal in cases of diarrhea, but even if abnormal, the WBC does not address fluid status.
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