The nurse is caring for a client admitted with vomiting and diarrhea after vacationing. Which of the following nursing interventions are appropriate for this client? (SELECT ALL THAT APPLY)
Monitoring intake and output
Providing good mouth and skin care
Obtaining daily weights
Assessing level of consciousness
Administering a loop diuretic
Correct Answer : A,B,C,D
A. Monitoring intake (fluids taken orally or intravenously) and output (urine, vomitus, diarrhea) helps assess fluid balance and hydration status. It is essential in clients with vomiting and diarrhea to prevent dehydration or fluid overload.
B. Vomiting and diarrhea can lead to dehydration and electrolyte imbalances, which may affect the skin and oral mucosa. Providing good mouth care (e.g., oral hygiene, hydration) and skin care (e.g., gentle cleansing, moisturizing) helps maintain comfort and prevent complications such as skin breakdown.
C. This may be appropriate depending on the severity of the client's condition and the healthcare provider's orders. Daily weights help monitor fluid balance and assess for changes in hydration status. However, in acute cases of vomiting and diarrhea, more frequent weights or other assessments of fluid status may be necessary.
D. Assessing the client's level of consciousness is important to monitor for signs of dehydration or electrolyte disturbances, which can affect neurological function. Changes in level of consciousness may indicate worsening dehydration or other complications that require prompt intervention.
E. Loop diuretics are medications used to increase urine output by inhibiting sodium reabsorption in the kidneys. However, they are not indicated for treating vomiting and diarrhea. In fact, administering diuretics could exacerbate fluid and electrolyte imbalances in a client who is already experiencing fluid loss through vomiting and diarrhea
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Hyperkalemia can have significant cardiac effects, potentially leading to life-threatening arrhythmias such as bradycardia, heart block, ventricular tachycardia, or ventricular fibrillation. As potassium levels rise, it affects the electrical conduction of the heart, leading to changes in the ECG (electrocardiogram) and potentially causing fatal arrhythmias.
B. While hyperkalemia primarily affects the cardiovascular system, gastrointestinal symptoms can also occur. These may include nausea, vomiting, abdominal pain, and diarrhea. However, these symptoms are typically less severe compared to cardiac manifestations. Monitoring for gastrointestinal symptoms helps in assessing overall clinical status but is not as critical as assessing cardiac function in the context of hyperkalemia.
C. Respiratory symptoms are not typically associated with hyperkalemia unless severe acid-base disturbances are present. Potassium imbalance itself does not directly affect respiratory function. Therefore, while it is important to assess respiratory status in any client, it is not the priority in the context of hyperkalemia.
D. Hyperkalemia can affect the nervous system, leading to symptoms such as muscle weakness, tingling sensations, and even paralysis in severe cases. However, neurologic symptoms usually occur at higher potassium levels or in the presence of significant electrolyte imbalances affecting nerve function.
Monitoring for neurologic symptoms is important but is generally secondary to assessing cardiac status in the context of approaching severe hyperkalemia.
Correct Answer is D
Explanation
D. It acknowledges the client's emotions by expressing empathy ("I am sad for you") and offering support ("I'll stay with you for a while if you need to talk"). This approach validates the client's grief, acknowledges the significance of their loss, and offers the opportunity for the client to express their feelings if they choose to do so.
A. This can inadvertently minimize the client's grief by suggesting that the nurse's losses are comparable or that the nurse understands the client's emotions completely.
B. It does not acknowledge or validate the client's current emotions and may overlook the complex feelings associated with losing a parent.
C. This response, although intended to provide encouragement, may not be therapeutic in the context of immediate grief. It suggests a future positive outcome from the loss without acknowledging the client's current emotional pain.
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