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concept of nursing 2
Nursing diagnosis and planning related to electrolyte imbalances
| Question | Answer |
|---|---|
| The nurse identifies hypokalemia in a patient. Which findings on the nursing assessment may be associated with this electrolyte imbalance? | -Bradycardia -Hypertension -Poor muscle tone - Poor skin turgor |
| The nurse identifies the nursing diagnosis of Imbalanced nutrition: less than body requirements related to anorexia, nausea, and vomiting. Which electrolyte imbalance should the nurse use as the | -- |
| “as evidenced by” portion for this nursing diagnostic statement? | Hypercalcemia |
| The nurse is providing care to a patient with electrolyte imbalance showing edema and shortness of breath. Which nursing diagnosis should the nurse include in the updated patient plan of care? | -Fluid volume excess related to electrolyte imbalances, as evidenced by edema and shortness of breath |
| The nurse identifies the nursing diagnosis Risk for electrolyte imbalance for an older adult patient experiencing nausea, vomiting, and diarrhea. Which is an accurate goal statement for the nurse to include in the patient’s plan of care? | Patient’s serum potassium level will be within the normal range of 3.5–5.0 mEq/L during the hospitalization. |
| The nurse is planning care for a patient whose nursing diagnosis is Decreased cardiac output related to electrolyte imbalance. The NOC for this nursing diagnosis is Cardiac pump effectiveness. | -- |
| Which indicators should the nurse monitor to determine the effectiveness of the current plan of care? | -Blood pressure -Heart sounds |
| Which goal should the nurse include in the plan of care for a patient whose priority nursing diagnosis is Acute pain related to electrolyte imbalances, as evidenced by muscle cramping? | Patient will report a muscle cramp pain rating of no more than 3 on a 1 to 10 numeric scale within 1 hour of implementing prescribed treatment. |
| Mr. Johnson continues to exhibit poor skin turgor and reports redness and irritation to the skin. The nurse adds Risk for impaired skin integrity to the plan of care. Which is an accurate goal that the nurse should include for the new nursing diagnosis? | Patient will report altered sensation or pain at risk areas as soon as noted. |
Created by:
Lightnning54
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