Which nursing diagnosis is priority for a client who has had vomiting and diarrhea for the past three days?

Fatigue related to excessive fluid loss.

Deficient fluid volume related to dehydration.

Risk for impaired skin integrity related to irritation.

Imbalanced nutrition: less than body requirements related to vomiting.

Answer and Explanation

The Correct Answer is B

This is the priority nursing diagnosis for a client who has had vomiting and diarrhea for the past three days because it poses the greatest threat to the client’s health and well-

being. Fluid loss can lead to hypovolemia, hypotension, shock, electrolyte imbalance, and renal failure.

Choice A is wrong because fatigue is a subjective symptom that may or may not be related to fluid loss.

It is not a priority over fluid volume deficit.

Choice C is wrong because impaired skin integrity is a potential problem that may occur due to irritation from vomiting and diarrhea, but it is not a priority over fluid volume deficit.

Choice D is wrong because imbalanced nutrition is a potential problem that may occur due to vomiting, but it is not a priority over fluid volume deficit.

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Correct Answer is B

Explanation

This indicates that the client has a fluid volume deficit, which is consistent with the signs and symptoms of low urine output, weight gain, irritability, and headache. The normal range for serum osmolality is 275 to 295 mOsm/Kg.

Choice A is wrong because hemoglobin 15.3 mg/dL is within the normal range of 12 to 18 mg/dL and does not correlate with fluid imbalance.

A. Blurred or cloudy vision. B. Burning sensation in the eye. C. Inability to produce tears. D. A swollen lacrimal gland.

Correct Answer is A

Explanation

Cataracts are a condition where the lens of the eye becomes opaque, causing impaired vision. Blurred or cloudy vision is a common symptom of cataracts.

Some possible explanations for the other choices are:

Choice B. Burning sensation in the eye. This is not a typical symptom of cataracts, but it could indicate an infection, allergy, or dry eye syndrome.

Choice C. Inability to produce tears. This is also not a typical symptom of cataracts, but it could indicate a problem with the lacrimal glands or ducts that produce and drain tears.

Choice D. A swollen lacrimal gland. This is not a symptom of cataracts, but it could indicate an inflammation or infection of the lacrimal gland, which is located near the upper eyelid.

Normal ranges for visual acuity are 20/20 for normal vision and 20/40 for mild impairment. Visual acuity can be measured using a Snellen chart or other methods.

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Which nursing diagnosis is priority for a client who has had vomiting and diarrhea for the past three days?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client’s 24-hour urine output is 750 mL and an amber color, oral intake is 1700 mL, and the weight has increased 3 kilograms in 2 days. The client is irritable and states “I have a headache.” Which laboratory value most correlates with these signs and symptoms?

Correct Answer is B

Explanation

A 68-year-old client diagnosed with cataracts should be assessed for which finding?

Correct Answer is A

Explanation

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