An older adult client is prescribed a diuretic and an antihypertensive drug as treatment for his hypertension. The client tells the nurse that he has been perspiring a lot lately and has had some diarrhea
Which nursing diagnosis would the nurse most likely identify as a priority?
A) Risk for Deficient Fluid Volume
B) Ineffective Sexuality Patterns
C) Activity Intolerance
D) Acute Pain
Ans: A
Feedback:
Risk for Deficient Fluid Volume would be the most likely priority because the client is receiving a diuretic and an antihypertensive drug. The risk increases if the client is older or confused. Ineffective Sexuality Patterns would be appropriate if the client were to experience sexual dysfunction related to drug therapy. Activity Intolerance would be appropriate if the client complained of feeling tired and weak. Acute Pain would be related to the development of a headache that may occur with angiotensin II receptor blockers or antiadrenergics.
You might also like to view...
Physical barriers to prevent harmful organisms entering the body and body cavities include
A) the process of lacrimation. B) the epiglottis. C) intestinal peristalsis. D) HCL acid in gastric secretions.
An individual calls the nurse help line and asks what the drug diphenhydramine is used for. The nurse knows that the medication is prescribed for which conditions? (Select all that apply.)
A) Urticaria B) Vasomotor rhinitis C) Productive cough D) Motion sickness E) Angioedema
The parents of a 10-year-old girl with a refractive error ask the nurse about the possibility of laser surgery to correct the vision. Which statement by the nurse would be most appropriate?
A) "As she gets older, her vision will begin to correct itself.". B) "Laser surgery typically is not done until she's 18 years old.". C) "She looks so cute in her glasses; why put her through surgery?" D) "She can use contact lenses soon, so surgery isn't necessary.".
An emergency department nurse is making a general appearance assessment on a preschool child just admitted to the emergency department. Which general assessment findings indicate the child "looks bad?" Select all that apply
a. Color pale b. Capillary refill less than 2 seconds c. Unwilling to separate from parents d. Cold extremities e. Lethargic