A patient experiencing multisystem fluid volume deficit has tachycardia, pale, cool skin, and decreased urine output. The nurse realizes these findings are most likely a direct result of which process?

Choice A: Comfort, Impaired is not a priority nursing diagnosis for this patient, because this condition is not directly related to the low sodium level. Comfort, Impaired is a state of physical or psychological discomfort that can affect the patient's well-being and quality of life.

Choice B: Disturbed Sensory Perception is a priority nursing diagnosis for this patient, because this condition is a serious complication of the low sodium level. Disturbed Sensory Perception is a state of altered or impaired perception of reality that can affect the patient's cognitive and neurological functions. Low sodium level can cause cerebral edema, which is a swelling of the brain that can lead to confusion, seizures, coma, and death.

Choice C: Deficient Fluid Volume is not a priority nursing diagnosis for this patient, because this condition is not the cause of the low sodium level. Deficient Fluid Volume is a state of decreased intravascular, interstitial, or intracellular fluid that can affect the patient's fluid and electrolyte balance. Low sodium level can be caused by excess fluid intake, fluid retention, or loss of sodium from the body.

Choice D: Risk for Injury is not a priority nursing diagnosis for this patient, because this condition is not specific to the low sodium level. Risk for Injury is a state of vulnerability to physical or psychological harm that can affect the patient's safety and health. Low sodium level can increase the risk of injury from falls, accidents, or seizures.

• Choice A Reason: This is correct because the client who has gastroenteritis and is febrile is likely to lose fluid through vomiting, diarrhea, and sweating. These losses can lead to dehydration, hypotension, and electrolyte imbalances. The nurse should monitor the client's vital signs, fluid intake and output, and weight, and administer fluids and electrolytes as ordered.
• Choice B Reason: This is incorrect because the client who has leftsided heart failure and has a BNP level of 600 pg/ml is likely to have fluid volume excess, not deficit. BNP is a hormone that is released by the heart when it is stretched by increased blood volume. A high BNP level indicates that the heart is failing to pump effectively and that fluid is accumulating in the lungs and other tissues. The nurse should monitor the client's respiratory status, oxygen saturation, edema, and weight, and administer diuretics and other medications as ordered.
• Choice C Reason: This is incorrect because the client who has endstage renal failure and is scheduled for dialysis today is likely to have fluid volume excess, not deficit. Renal failure impairs the kidney's ability to excrete fluid and waste products, leading to fluid retention and azotemia. Dialysis is a procedure that removes excess fluid and toxins from the blood using an artificial membrane. The nurse should monitor the client's blood pressure, fluid intake and output, weight, and laboratory values, and prepare the client for dialysis as ordered.
• Choice D Reason: This is incorrect because the client who has been NPO since midnight for endoscopy is unlikely to have a significant fluid volume deficit, unless they have other risk factors or comorbidities. NPO means nothing by mouth, which is a common instruction before certain procedures or surgeries to prevent aspiration. Endoscopy is a procedure that uses a flexible tube with a camera to examine the digestive tract. The nurse should verify the client's NPO status, check their consent form, and administer preoperative medications as ordered.