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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The popliteal artery is a major blood vessel that runs behind the knee and supplies blood to the lower leg. Sitting with knees crossed can compress this artery and reduce blood flow to the leg.
This can cause numbness, tingling, or pain in the leg. It can also increase the risk of blood clots or varicose veins.
Choice A is wrong because sitting with knees crossed does not decrease the risk of skin breakdown behind the knee. In fact, it may increase the risk by causing friction or pressure on the skin.
Choice B is wrong because sitting with knees crossed does not eliminate the pain of arthritis in the lower legs.
Arthritis is a joint inflammation that causes pain, stiffness, and swelling. Sitting with knees crossed can worsen these symptoms by putting more stress on the knee joints.
Choice D is wrong because sitting with knees crossed does not avoid irritation of the knee joints.
On the contrary, it can cause irritation by overstretching the knee ligaments and muscles
Correct Answer is A
Explanation
A client who grimaces during a dressing change is showing a nonverbal sign of pain. Grimacing is an expression of facial muscles that indicates discomfort or distress.
The nurse should record this as a symptom of pain and ask the client to rate the pain using a numeric or visual scale.
Choice B is wrong because an elevated heart rate while exercising is not necessarily a symptom of pain. It could be a normal response to increased physical activity or a sign of other conditions such as anxiety, dehydration, or fever.
Choice C is wrong because crying during a procedure is not a reliable indicator of pain. Crying is an emotional response that can be influenced by many factors such as fear, stress, or sadness.
The nurse should not assume that the client is in pain based on crying alone and should ask the client about the reason for crying and the level of pain.
Choice D is wrong because saying “I feel achy all over” is not a specific description of pain.
Aching is a vague term that can refer to different sensations such as soreness, stiffness, or cramping.
The nurse should ask the client to clarify what kind of pain they are feeling, where it is located, how severe it is, and what makes it better or worse.
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