Instructions:
Use this scenario for the next 4 questions.
Indicate which assessment findings correlate with the nursing problem you identified. (Select all that apply)
Watery diarrhea for 3 days.
Chronic kidney disease, which has been managed with diuretics and fluid restrictions.
Lung sounds are clear.
No nausea and vomiting.
History of hypertension.
Blood urea nitrogen (BUN).
Correct Answer : A,B,E,F
Choice A reason:
Watery diarrhea for 3 days is a significant finding that correlates with fluid and electrolyte imbalances. Diarrhea leads to the loss of fluids and electrolytes, which can result in dehydration and electrolyte disturbances such as hypokalemia or hyperkalemia. In this case, the patient’s potassium level is elevated (5.6 mEq/L), which could be a result of the body’s attempt to compensate for the loss of other electrolytes. Diarrhea also contributes to the patient’s weakness and lightheadedness due to dehydration.
Choice B reason:
Chronic kidney disease, which has been managed with diuretics and fluid restrictions, is another critical factor. Chronic kidney disease (CKD) affects the body’s ability to regulate fluid and electrolytes. The use of diuretics can exacerbate electrolyte imbalances, particularly potassium levels. In this scenario, the patient’s elevated potassium level (5.6 mEq/L) is concerning, as CKD patients are at higher risk for hyperkalemia due to decreased renal excretion of potassium. The combination of CKD and recent diarrhea increases the complexity of managing the patient’s fluid and electrolyte balance.
Choice C reason:
Lung sounds are clear is an important assessment finding but does not directly correlate with the primary nursing problem of fluid and electrolyte imbalance. While clear lung sounds indicate that the patient is not experiencing respiratory complications such as pulmonary edema or infection, this finding does not address the immediate concerns related to fluid loss and electrolyte disturbances. Therefore, it is not a priority in this context.
Choice D reason:
No nausea and vomiting is a relevant finding but does not directly correlate with the primary nursing problem. The absence of nausea and vomiting is positive, as it indicates that the patient is not losing additional fluids and electrolytes through emesis. However, it does not address the significant fluid loss from diarrhea or the electrolyte imbalances that are the primary concerns in this scenario.
Choice E reason:
History of hypertension is a relevant factor in the patient’s overall health status. Hypertension can complicate the management of fluid and electrolyte imbalances, particularly in patients with CKD. The use of antihypertensive medications and diuretics can affect electrolyte levels and fluid balance. In this case, the patient’s blood pressure is slightly low (109/70), which could be related to dehydration from diarrhea and the effects of antihypertensive medications. This history is important for understanding the patient’s baseline and potential complications.
Choice F reason:
Blood urea nitrogen (BUN) is elevated at 30 mg/dL, which is above the normal range (6-24 mg/dL). An elevated BUN level indicates impaired kidney function and can be a sign of dehydration or renal insufficiency. In the context of CKD and recent diarrhea, an elevated BUN suggests that the kidneys are struggling to manage the body’s waste products and fluid balance. This finding is critical for understanding the extent of the patient’s fluid and electrolyte imbalances and guiding appropriate interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is False
Explanation
Choice A: True
The statement that all patient teaching occurs in a formalized teaching session is not accurate. While formalized teaching sessions are an important aspect of patient education, they are not the only method used. Formal sessions are structured and planned, often involving detailed explanations, demonstrations, and the use of educational materials. These sessions are beneficial for covering complex topics and ensuring that patients and caregivers have a thorough understanding of their health conditions and treatment plans.
Choice B: False
Patient teaching can occur in various settings and formats, not just in formalized teaching sessions. Informal teaching moments are equally important and often occur during routine interactions between healthcare providers and patients. These moments can include brief explanations, answering questions, and providing reassurance during procedures or daily care activities. Informal teaching is flexible and can be tailored to the patient’s immediate needs and readiness to learn, making it a crucial component of effective patient education.
Correct Answer is ["B","C","E","F","H"]
Explanation
Choice A: Agency policy
While agency policy provides guidelines for reassessment intervals, it is not the primary factor in determining the specific time frame for reassessing a patient’s pain level. Policies serve as a general framework, but individual patient needs and clinical judgment should guide the reassessment timing.
Choice B: Type of intervention
This is a correct answer. The type of pain management intervention used significantly influences the reassessment time frame. For example, after administering intravenous pain medication, reassessment should occur sooner compared to oral medications due to the faster onset of action. Different interventions have varying durations of effectiveness, necessitating tailored reassessment intervals.
Choice C: Pain severity
This is another correct answer. The severity of the patient’s pain is a crucial factor in determining reassessment timing. Patients experiencing severe pain may require more frequent reassessments to ensure that pain management strategies are effective and to make timely adjustments if needed.
Choice D: If family members are present in the patient’s room
The presence of family members in the patient’s room is not a primary factor in determining the reassessment time frame. While family members can provide valuable support and information, the focus should remain on the patient’s clinical needs and the effectiveness of pain management interventions.
Choice E: The patient’s psychosocial condition
This is a correct answer. The patient’s psychosocial condition, including their emotional and mental state, can impact their perception of pain and response to pain management. Patients with anxiety, depression, or other psychosocial issues may require more frequent reassessments to address both physical and emotional aspects of pain.
Choice F: Risks for adverse effects
This is also a correct answer. The potential for adverse effects from pain management interventions necessitates careful monitoring and timely reassessment. For instance, opioids carry risks of respiratory depression and sedation, requiring close observation and frequent reassessment to ensure patient safety.
Choice G: Workload of the nurse
While the nurse’s workload can influence the practical aspects of care delivery, it should not dictate the reassessment time frame. Patient needs and clinical priorities should guide reassessment intervals, with workload management being a secondary consideration.
Choice H: The patient’s physical condition
This is the final correct answer. The patient’s overall physical condition, including comorbidities and current health status, affects their response to pain management and the need for reassessment. Patients with complex medical conditions may require more frequent monitoring to ensure effective pain control and to promptly address any complications.
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