When caring for a client with severe diarrhea, which focused assessment is most important for the practical nurse (PN) to complete before reporting to the charge nurse?
Check for external rectal hemorrhoids.
Note inflammation in the perineal area.
Observe for signs of fluid volume deficit.
Determine any changes in sleep patterns.
The Correct Answer is C
A. Check for external rectal hemorrhoids: Hemorrhoids may cause discomfort during diarrhea, but they are not the most urgent concern. The primary issue with severe diarrhea is the risk of dehydration and electrolyte imbalance, which can become life-threatening.
B. Note inflammation in the perineal area: While important for skin care and comfort, perineal inflammation does not pose the immediate systemic risk that fluid volume deficit does. Skin assessment can be addressed after ensuring the client's vital signs and hydration status are stable.
C. Observe for signs of fluid volume deficit: Severe diarrhea leads to significant fluid and electrolyte losses. Signs such as hypotension, tachycardia, dry mucous membranes, and decreased urine output indicate fluid volume deficit, which requires urgent intervention to prevent shock and organ dysfunction.
D. Determine any changes in sleep patterns: Sleep disturbances can occur with illness but are not as immediately critical to assess as fluid and electrolyte status. Identifying fluid volume deficit must be prioritized to prevent rapid clinical deterioration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The amount of fluid the client drank today: Although fluid intake affects weight, daily weights are intended to reflect overall fluid and nutritional changes over time, not just today's intake. Monitoring intake is important but not the most critical factor in conducting daily weights consistently.
B. When the client wants to be weighed: While respecting the client's preferences is important for cooperation, clinical accuracy requires consistency in timing and conditions, not simply weighing at the client's preferred time.
C. When the client was last weighed: Knowing when the client was last weighed ensures consistency and accuracy for monitoring trends. Daily weights should be taken at the same time each day, ideally in the morning before eating and after voiding, to accurately track fluid balance and body mass changes.
D. The amount of food the client ate today: Food intake affects weight slightly, but the purpose of daily weights is to detect significant changes, such as fluid retention or loss. Weighing under consistent conditions matters more than focusing on the day's food intake.
Correct Answer is A
Explanation
A. Increase the daily oral fluid intake: Increasing fluid intake is one of the best non-pharmacological strategies to prevent constipation, especially in older adults. Adequate hydration helps soften stool, promotes regular bowel movements, and supports overall digestive health during travel and routine changes.
B. Decrease the fat content in your diet: Reducing dietary fat is more related to managing cardiovascular health rather than preventing constipation. Fats themselves do not contribute significantly to constipation, and this advice would not directly address the client's specific concern.
C. Use an over-the-counter (OTC) stool softener: While stool softeners can be useful, recommending their routine use without first trying dietary and lifestyle modifications is not the best initial approach. Relying on medications can sometimes lead to dependency or mask underlying issues.
D. Eat a high-protein diet: High-protein diets without sufficient fiber and fluids can actually worsen constipation. Protein is important for overall health, but preventing constipation primarily requires fiber intake and adequate hydration rather than increased protein alone.
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