The mother of a 3-month-old infant comes to emergency department and states, "My baby has been having severe diarrhea for 4 days. She is crying all the time
" In formulating the plan of care to moderate the diarrhea, the nurse focuses her intervention(s) on which of the following? Select all that apply.
a. Fluid management
b. Electrolyte balance
c. Skin integrity
d. Excessive cryin
A, B, C
Patients with diarrhea are at risk for fluid and electrolyte imbalance. Water and potassium loss are the primary concerns. Infants, young children, and the frail elderly are most vulnerable and may require hospitalization and intravenous fluid replacement therapy. Ideally, oral liquids replace the lost fluid and potassium. Priority nursing interventions, particularly for the infant, must focus on treating the diarrhea itself, fluid and electrolyte balance/imbalance, and impaired skin integrity. Although crying distresses parents, managing the infant's crying is not a priority at this time, and it will usually cease once the infant is feeling better and responding to treatment.
You might also like to view...
Beginning with Florence Nightingale, many definitions of nursing have been put forth by individual nurses and by nursing organizations. Which of the following statements best describes an aspect of the changes in these definitions over time?
A) Drawing a clear distinction between the art of nursing and science of nursing B) Definitions of nursing that have become narrower in scope over time C) Characterization of nursing as a discipline that is a distinct alternative to medical treatment D) Definition of an independent health care practice that is not solely dependent on physicians
During the examination of an adult male the nurse notes thick, curly hair over the pubis area, a pear-shaped scrotum, and slightly darkened skin on the penis. The nurse would correctly choose which of the following actions?
1. Ask the client about recent illnesses. 2. Ask the client about sexual practices. 3. Notify the healthcare provider the findings. 4. Document the findings as normal.
An ear temperature probe that consistently reports body temperature at a degree lower than the patient's actual temperature has what type of reliability or validity problem?
a. Reduced reliability, systematic error b. Reduced validity, random error c. Increased validity, systematic error d. Increased validity, random error
During an assessment a patient with multiple substance addictions asks why the need for drugs and alcohol is so great. What should the nurse include when responding to this patient?
Select all that apply. 1. "Substance abuse is sign of weakness and boredom with life." 2. "Alcohol reinforces the transmission of opioids in the system." 3. "There is a human tendency to seek pleasure and avoid stress and pain." 4. "It really depends upon genetic makeup and if your parents used drugs." 5. "One substance in the brain, dopamine, is responsible for drug-seeking behavior."