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
During the introductory (orientation) phase of the nurse-client relationship, the nurse should focus on establishing trust and rapport with the client. One way to do this is by eliciting information from the client through active listening and open-ended questioning. This allows the nurse to gather important information about the client's health status, needs, and concerns and helps to establish a foundation for the therapeutic relationship. Reviewing progress toward personal objectives and encouraging self-exploration is more appropriate for later phases of the relationship.
Talking with others who have information about the client may also be helpful, but it is important to prioritize direct communication with the client during this phase.
Correct Answer is A
Explanation
This statement indicates a need for further teaching because it is not accurate. Positioning a client in good body alignment and changing the position regularly are essential aspects of nursing practice, but the position should be changed more frequently than every 3 hours. It is generally recommended to reposition clients at least every 2 hours to prevent pressure ulcers and other complications. The other options (Frequent change in position helps to prevent muscle discomfort, undue pressure resulting in pressure ulcers, damage to superficial nerves and blood vessels, and contractures; Any position, correct or incorrect, can be detrimental if maintained for a prolonged period; and For all clients, it is important to assess the skin and provide skin care before and after a position change) are accurate statements and do not indicate a need for further teaching.
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