The nurse understands that examples of sensible fluid loss in a client are: (SELECT ALL THAT APPLY)

Diarrhea

Urinary output

Profuse sweating

Vomiting

Increased respiratory effort

Answer and Explanation

Correct Answer : B,E

A. Diarrhea: Diarrhea results in fluid loss from the body and is considered an insensible fluid loss rather than sensible fluid loss. Sensible fluid loss refers to measurable fluid losses such as urine output and sweating.

B. Urinary output: Urinary output represents sensible fluid loss as it is measurable and reflects the volume of fluid excreted by the kidneys. Monitoring urinary output is essential for assessing fluid balance in clients.

C. Profuse sweating: Profuse sweating results in sensible fluid loss as it is measurable and can lead to significant fluid depletion if not adequately replaced. Sweating is the body's mechanism for thermoregulation, and excessive sweating, such as during strenuous exercise or in hot environments, can result in notable fluid loss.

D. Vomiting: Vomiting results in fluid loss from the body and is considered an insensible fluid loss rather than sensible fluid loss. While vomiting leads to the expulsion of gastric contents and fluids, the volume of fluid loss is not easily measurable compared to urine output or sweating.

E. Increased respiratory effort: Increased respiratory effort, such as during heavy breathing or respiratory distress, can result in sensible fluid loss through exhalation. This loss occurs as water vapor is expelled from the lungs during respiration. Monitoring respiratory rate and effort can provide insights into fluid balance in clients, particularly in conditions such as respiratory infections or heart failure.

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Correct Answer is ["B","C"]

Explanation

A. Quickly resuming the client's normal food intake: This is not recommended, as the client's gastrointestinal system needs time to recover from food poisoning. Resuming normal food intake too quickly may exacerbate symptoms or prolong recovery. It's essential to give the gastrointestinal system time to heal and gradually reintroduce foods as tolerated.

Answer: B. Requesting a prescription for an antidiarrheal drug from the provider.

C. Encouraging easily digestible foods when the diarrhea stops.

Rationale:

When caring for a client with profuse diarrhea from food poisoning, the nurse's interventions should focus on managing symptoms, preventing dehydration, and promoting recovery. Options B and C are appropriate nursing interventions for this scenario:

B. Requesting a prescription for an antidiarrheal drug from the provider: Antidiarrheal medications such as loperamide (Imodium) may be prescribed to help control diarrhea and reduce fluid loss. These medications work by slowing down bowel motility and can provide symptomatic relief, particularly for clients with profuse diarrhea from food poisoning. However, the use of antidiarrheal drugs should be guided by a healthcare provider's prescription to ensure appropriate dosing and monitoring, especially considering individual client factors and potential contraindications.

C. Encouraging easily digestible foods when the diarrhea stops: This is the correct option. Once the diarrhea subsides, it is appropriate to encourage the client to gradually reintroduce easily digestible foods. These foods are gentle on the digestive system and help prevent further irritation or upset. Examples of easily digestible foods include bananas, rice, applesauce, toast (BRAT diet), boiled potatoes, boiled chicken, and clear broths.

D. Limiting the client's fluid intake to about 1000 mL/day: Fluid intake should be encouraged rather than limited, especially in cases of profuse diarrhea. Diarrhea can lead to significant fluid loss and dehydration, so it's crucial to ensure adequate hydration. The client should be encouraged to drink clear fluids such as water, electrolyte solutions, and herbal teas to replace lost fluids and electrolytes.

A. should not be asked about religion or spirituality B. has abandoned religion due to illness C. could be interviewed about personal experiences that guide their life D. does not believe in a higher power

Correct Answer is C

Explanation

A. The client should not be asked about religion or spirituality: This option is not appropriate. Religion and spirituality are important aspects of holistic care and should be addressed based on the client's preferences and needs. Avoiding discussions about religion or spirituality based on the client's statement may overlook opportunities for supportive care.

B. The client has abandoned religion due to illness: There is no evidence to suggest that the client has abandoned religion due to illness based solely on the statement provided. Assuming such a conclusion without further assessment would be inappropriate and potentially inaccurate.

C. The client could be interviewed about personal experiences that guide their life: This is the correct interpretation. The client's statement indicates that they identify as spiritual but do not adhere to a specific religious denomination. This suggests that the client may have personal beliefs, values, or experiences that guide their life and worldview. The nurse can explore these aspects through open-ended questions to gain insight into the client's spiritual needs and preferences.

D. The client does not believe in a higher power: There is no indication from the client's statement that they do not believe in a higher power. The statement simply suggests that the client does not affiliate with a specific religious denomination, but it does not necessarily imply atheism or disbelief in a higher power.

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The nurse understands that examples of sensible fluid loss in a client are: (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

A client has with profuse diarrhea from food poisoning contracted at a company picnic 12 hours ago. The nurse's care for this client should include: ...

Correct Answer is ["B","C"]

Explanation

A home care nurse is completing a comprehensive assessment & sees that the client has written "spiritual but no specific religious denomination". How should the nurse interpret this data? The client...

Correct Answer is C

Explanation

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