A nursing diagnosis of "Risk for Deficient Fluid Volume" related to excessive fluid loss, secondary to diarrhea and vomiting was implemented for a home health client who began with these symptoms 5 days ago. A goal was set that the client's symptoms would be eliminated within 48 hours. The client is being seen after a week and has had no diarrhea or vomiting for the past 5 days. What should the nurse do?
Document that the potential problem is being prevented from recurring.
Document that the problem has been resolved and the goal has been met.
Assume that whatever the cause was, the symptoms may return, but the goal was met.
Keep the problem on the care plan in case the symptoms return.
The Correct Answer is B
The nursing diagnosis was "Risk for Deficient Fluid Volume" related to excessive fluid loss, secondary to diarrhea and vomiting. The goal was set that the client's symptoms would be eliminated within 48 hours. The client is being seen after a week and has had no diarrhea or vomiting for the past 5 days, indicating that the problem has been resolved. Therefore, the nurse should document that the problem has been resolved and the goal has been met.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
When a labor and delivery nurse tells a coworker that a client of Asian descent probably did not want any pain medication because "Asian women typically are stoic," the nurse is expressing a belief known as a stereotype. A stereotype is an oversimplified and often inaccurate generalization about a group of people. The other options (Bias, Ethnic slur, and Stigma) are not directly related to this situation.
Correct Answer is A
Explanation
The nursing process consists of five phases: assessment, diagnosis, planning, implementation, and evaluation. During the assessment phase, the nurse gathers information about the client's health status and needs. In this scenario, the nurse is conducting a dressing change and notes a new area of skin breakdown. This observation is part of the assessment phase of the nursing process, as the nurse is gathering information about the client's condition. The other phases of the nursing process involve analyzing the information gathered during assessment (diagnosis), developing a plan of care (planning), carrying out interventions (implementation), and evaluating the effectiveness of care (evaluation).
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today