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 outcome indicates that the client has resolved their constipation and has a regular pattern of defecation without difficulty or discomfort.

Choice A is wrong because taking a laxative daily can worsen constipation by causing dependency and reducing the natural peristalsis of the colon.

Choice C is wrong because requesting a bedpan every four hours does not necessarily mean that the client has bowel movements. It may indicate that the client has difficulty passing stool or has a sensation of incomplete emptying.

Choice D is wrong because having a bowel movement within 72 hours is still considered constipation. Constipation is diagnosed when bowel movements are associated with at least two of the following symptoms, occurring in the past three months with an onset of symptoms of at least six months: Less than three spontaneous bowel movements per week, Lumpy or hard stools from at least 25% of bowel movements.

A. “Surgery is your only choice. You need this operation.”. B. “Whether or not you have the surgery is your choice. What is your understanding of the situation?”. C. “I hear you. D. I wouldn’t want surgery either.

Correct Answer is B

Explanation

What is your understanding of the situation?”. This is a therapeutic response because it respects the client’s autonomy and invites them to share their concerns and feelings about the surgery.

Choice A is wrong because it is authoritarian and dismissive of the client’s feelings. It does not acknowledge the client’s right to refuse treatment.

Choice C is wrong because it is nontherapeutic and shows agreement with the client’s refusal. It also implies that the nurse and the doctor are on different sides.

Choice D is wrong because it is manipulative and guilt-tripping. It implies that the client does not care about their loved ones or their own life.

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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

Which outcome is expected for a client who has a diagnosis of constipation? The client:.

Correct Answer is B

Explanation

A client states “I don’t want to have surgery.” Which of the following is a therapeutic response to the client?

Correct Answer is B

Explanation

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