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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A stage II pressure ulcer is a wound that presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. This type of wound is caused by unrelieved pressure on the skin, resulting in damage to the underlying tissue. In this scenario, the nurse notes an area of tissue injury on the client's sacral area that matches the description of a stage II pressure ulcer. Stage I pressure ulcers are characterized by non-blanchable erythema of intact skin, while stage III and IV pressure ulcers involve full-thickness tissue loss and may expose underlying muscle, bone, or other structures.

A. Review the client's progress toward personal objectives. B. Encourage the client to use self-exploration. C. Elicit information from the client. D. Talk with others who have information about the client.

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. What is the correct name of this wound?

Correct Answer is A

Explanation

A nurse is caring for a client in the introductory (orientation) phase of the nurse-client relationship. Which of the following communication techniques should the nurse use during this phase?

Correct Answer is C

Explanation

The nurse is collecting equipment to administer a unit of packed red blood cells. Which IV ﬂuid should be used to initiate the IV for this transfusion?

A client recovering from surgery asks the nurse why turning, deep breathing, and coughing exercises need to be done. How should the nurse respond?

A nurse is evaluating a nursing student's understanding of positioning clients. Which of the following statements indicates a need for further teaching?

During discharge planning, the nurse is responsible for teaching the client how to maintain comfort, promote healing, and restore wellness. However, one of the actions listed below is not correct.

Which of the following is marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnoea?

A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate?

A nurse is conducting a lung assessment on a client suspected of having pneumonia. Which finding should the nurse report to the physician immediately?