After conducting a physical assessment for an adult client, the ...

[DyllonKazuo]

After conducting a physical assessment for an adult client, the nurse discusses the assessment with a co-worker and states that the client's beliefs and actions regarding common health practices seem weird.
 
  Based on this data, which action by the nurse is the most appropriate?
  A) Repeat the assessment later in the day.
  B) Determine the culture with which the client identifies.
  C) Write a nursing diagnosis to address the weird beliefs and actions.
  D) Communicate the findings to the health-care team.

Question 2

A client is admitted to the emergency department for vomiting and diarrhea that has lasted 4 days. The client's current weight is 154 pounds. The health care provider has diagnosed the client with a viral infection.
 
  The nurse has been monitoring intravenous fluids and urine output. Which urinary output indicates the efforts to rehydrate this client have been successful?
  A) 40 mL per hour
  B) 20 mL per hour
  C) 25 mL per hour
  D) 30 mL per hour

[stanleka1]

Answer to Question 1

Answer: B

A thorough assessment is needed before proceeding with other steps of the nursing process. Behavior that is considered weird in one cultural context may be considered desirable in another. While findings will be communicated and used for nursing diagnosis formulation, these steps are built upon a thorough assessment. Repeating the assessment will most likely result in the same incomplete data. Writing a nursing diagnosis before investigating the client's culture would be premature.

Answer to Question 2

Answer: A

Normal urine output for adult client is at least 0.5 mL/kg per hour. This client weighs 70 kg, so adequate urine output would be at least 35 mL per hour. The only option that indicates adequate urine output is 40 mL per hour.