While caring for a client with end-stage renal disease, the nurse ...

[ashley]

While caring for a client with end-stage renal disease, the nurse tracks the client's serum albumin level. For which nursing diagnosis is the action most indicated?
 
  A) Excess Fluid Volume
  B) Imbalanced Nutrition: Less Than Body Requirements
  C) Risk for Ineffective Perfusion
  D) Risk for Infection

Question 2

During a home visit, the nurse is concerned that an older adult client is developing renal failure. The client has no history of cardiovascular disease. Which data in the client's assessment caused the nurse to have this concern?
 
  Select all that apply.
  A) Progressive edema
  B) Complaints of hip joint pain
  C) New onset of hypertension
  D) Recent increase in hunger and thirst
  E) Warm moist skin

[jojobee318]

Answer to Question 1

Answer: B

Interventions appropriate for the diagnosis of Imbalanced Nutrition: Less Than Body Requirements include monitoring laboratory values such as such as serum albumin. Assessing for edema and monitoring heart rate and blood pressure would be interventions for the diagnosis of Excess Fluid Volume. Monitoring for orthostatic blood pressure changes would be appropriate for the diagnosis of Risk for Ineffective Perfusion. Monitoring the white blood cell count would be an intervention appropriate for the diagnosis of Risk for Infection.

Answer to Question 2

Answer: A, C

The manifestations of renal failure often are missed in aging clients because edema may be attributed to heart failure or high blood pressure to preexisting hypertension. Hip joint pain is not a manifestation of renal failure in the older client. An increase in hunger and thirst could be an indication of diabetes mellitus and not renal failure in the older client. A client with renal failure will have pale dry skin with poor turgor.

[ashley]

Thank you

[jojobee318]

Happy to help you