A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and has lost 25% of body weight. The patient’s current serum potassium is 2.7 mg/dl. Which nursing diagnosis is most applicable?
a. Adult failure to thrive, related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss
b. Disturbed energy field, related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia
c. Ineffective health maintenance, related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia
d. Imbalanced nutrition: less than body requirements, related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia
Ans: d. Imbalanced nutrition: less than body requirements, related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia
Explanation: The patient's history and laboratory results support the fourth nursing diagnosis. Available data do not confirm that the patient uses laxatives, induces vomiting, or exercises excessively. The patient has hypokalemia rather than hyperkalemia.
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a. Difficulty hearing b. Buildup of cerumen c. Ear pain d. Ringing in the ears
The nurse is providing care for a patient who is showing signs and symptoms of shock
The nurse is choosing and prioritizing nursing interventions that are framed in the knowledge that the restoration of adequate tissue perfusion is essential to the patient's safe recovery. Tissue perfusion results from the interplay of which of the following essential factors? Select all that apply. A) Hemostasis B) Balanced fluid intake and output C) Systemic vascular resistance D) Cardiac output E) Level of consciousness
An older client asks the nurse what can be done to prevent a respiratory infection during the winter months. How should the nurse respond to this client? Select all that apply.
1. Stay active with daily exercise. 2. Don't smoke and avoid secondhand smoke. 3. Wash the hands often and get a flu vaccination. 4. Eat a healthy diet and maintain a normal weight. 5. Ask a family member to perform shopping duties.