Which nursing diagnosis is priority for a client who has had vomiting and diarrhea for the past three days?
Fatigue related to excessive fluid loss.
Deficient fluid volume related to dehydration.
Risk for impaired skin integrity related to irritation.
Imbalanced nutrition: less than body requirements related to vomiting.
The Correct Answer is B
This is the priority nursing diagnosis for a client who has had vomiting and diarrhea for the past three days because it poses the greatest threat to the client’s health and well-
being. Fluid loss can lead to hypovolemia, hypotension, shock, electrolyte imbalance, and renal failure.
Choice A is wrong because fatigue is a subjective symptom that may or may not be related to fluid loss.
It is not a priority over fluid volume deficit.
Choice C is wrong because impaired skin integrity is a potential problem that may occur due to irritation from vomiting and diarrhea, but it is not a priority over fluid volume deficit.
Choice D is wrong because imbalanced nutrition is a potential problem that may occur due to vomiting, but it is not a priority over fluid volume deficit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Use a fresh washcloth when cleaning each eye. This is because using the same washcloth for both eyes can transfer microorganisms from one eye to the other and cause cross-infection.
The other choices are wrong because:
Choice A is wrong because wiping from the outer part of the eye toward the inner portion can introduce microorganisms into the tear ducts and cause infection.
Choice B is wrong because rinsing the washcloth before washing the second eye does not eliminate all the microorganisms that might be on the cloth.
Choice C is wrong because asking the client to roll the eyes upward does not prevent spreading organisms from one eye to the other when bathing a client.
Normal ranges for eye hygiene are to use a clean washcloth or cotton ball for each eye, wipe from the inner to the outer canthus, and use warm water or saline solution.
Correct Answer is B
Explanation
“I apologize for not hearing you say that. Is there a better day for you?”.
This response shows empathy and respect for the client’s feelings and preferences.
It also invites the client to collaborate on finding a solution that works for both parties. Choice A is wrong because it is rude and defensive.
It does not acknowledge the client’s frustration or offer any alternatives. Choice C is wrong because it is dismissive and paternalistic.
It does not respect the client’s autonomy or consider the client’s reasons for not being able to come back on Friday.
Choice D is wrong because it is persuasive and manipulative.
It does not address the client’s concerns or explore other options.
The nurse-client relationship is based on trust, respect, and collaboration.
The nurse should use therapeutic communication skills to maintain a positive rapport with the client and promote their health and well-being.
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