The nursing diagnosis of Excess Fluid Volume is made for a patient with chronic kidney disease. Which of the following data is most important for the nurse to collect for this patient based on the nursing diagnosis?
daily weight
vital signs
intake and output
skin turgor
The Correct Answer is C
A. Daily weight monitoring is important for assessing fluid status but may not provide real-time information about fluid balance changes.
B. Vital signs are important for overall assessment but may not specifically address the nursing diagnosis of Excess Fluid Volume unless there are significant changes indicative of fluid overload or dehydration.
C. Monitoring intake and output provides direct information about fluid balance and renal function, helping to identify trends and assess the effectiveness of interventions aimed at managing fluid volume.
D. Skin turgor assessment is useful for evaluating hydration status but may not provide comprehensive data on fluid volume excess alone.
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Related Questions
Correct Answer is C
Explanation
A. These values are within the normal range and not indicative of chronic kidney disease.
B. While an elevated BUN is present, the serum creatinine level is within the normal range, which is not consistent with chronic kidney disease.
C. Both BUN and serum creatinine levels are elevated, indicating impaired kidney function and consistent with chronic kidney disease.
D. These values are within the normal range and not indicative of chronic kidney disease.
Correct Answer is ["A","B","C","D","E"]
Explanation
First, Hodgkin lymphoma (HL) is commonly characterized by painless lymphadenopathy and is not painful, as stated above. Secondly, HL is often characterized by a low-grade fever rather than a high fever. Third, the presence of Bence-Jones cells in a laboratory test is not associated with Hodgkin lymphoma but indicates multiple myeloma, a different type of cancer. Fourth, Hodgkin disease is indeed a form of cancer; it is a malignancy of the lymphatic system. The nurse's statement that it is "not really cancer" is incorrect and misleading. Fifth, palliative radiation therapy is typically used to relieve symptoms in advanced stages of cancer or non-curative scenarios. However, for stage 1 Hodgkin lymphoma, the treatment usually involves chemotherapy and/or radiation therapy with curative intent, not palliative. Joe's nurse should provide accurate information about the nature of Hodgkin's disease and its treatment options, which are based on the stage and specific characteristics of the lymphoma.
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