A nurse is planning care for a client with acute kidney injury. The nurse should recognize that which assessment data best supports the nursing diagnosis of Excess Fluid Volume?
Wheezing in all lung fields.
Pitting edema in bilateral lower extremities.
Oral fluid intake of 2000 mL in 24 hours.
Significant fatigue for more than one month.
The Correct Answer is B
A. Wheezing in all lung fields may indicate respiratory issues but does not directly support the diagnosis of Excess Fluid Volume.
B. Pitting edema in bilateral lower extremities is a classic sign of fluid overload, which directly supports the diagnosis of Excess Fluid Volume.
C. An oral fluid intake of 2000 mL in 24 hours is within normal limits for an adult and does not necessarily indicate Excess Fluid Volume without other symptoms.
D. Significant fatigue for more than one month could be related to a variety of conditions and is too nonspecific to support the diagnosis of Excess Fluid Volume without additional assessment data.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
A. Elevated temperature: Elevated temperature is not typically associated with advanced COPD unless there is an underlying infection. Infections such as pneumonia may exacerbate COPD symptoms but are not universal findings in advanced COPD.
B. Pursed-lip breathing: Pursed-lip breathing is a common compensatory mechanism seen in clients with COPD. It helps to slow down the rate of expiration and prevents alveolar collapse, improving gas exchange.
C. Clubbing of the fingers: Clubbing of the fingers is not typically associated with COPD. It is more commonly seen in conditions such as chronic hypoxemia, congenital heart disease, and certain lung diseases like bronchiectasis.
D. Concave chest: In advanced COPD, the chest may appear hyperinflated with a barrel-shaped chest due to air trapping. The presence of a concave chest is not characteristic of COPD.
E. Dyspnea at rest: Dyspnea, or difficulty breathing, is a hallmark symptom of COPD. In advanced stages, clients may experience dyspnea even at rest due to severe airflow limitation and impaired gas exchange.
Correct Answer is D
Explanation
A. Manage the emotions: Managing emotions is an important aspect of conflict resolution, but it typically occurs after the problem has been clarified and during the negotiation process to promote constructive dialogue and prevent escalation of conflict.
B. Breaking the ground rules: Breaking the ground rules refers to violating established guidelines or principles for effective communication and negotiation. This step is not evident in the scenario described.
C. Disregard the conflict: Disregarding the conflict would involve ignoring or avoiding addressing the issues altogether, which is not an appropriate approach to conflict resolution. The scenario indicates that the nurse manager is actively engaged in addressing the conflict.
D. Clarify the problem: In negotiation, clarifying the problem involves identifying and defining the underlying issues or concerns contributing to the conflict. Creating a list of main issues helps ensure that all parties have a clear understanding of what needs to be addressed and provides a foundation for developing potential solutions.
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