Answer to Question 1
B
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A Tachycardia is associated with fluid volume deficit.
B Hypertension is a symptom of fluid volume excess.
C Dry mucous membranes are symptomatic of fluid volume deficit and dehydration, not excess fluid.
D Fever is a symptom of fluid volume deficit.
Answer to Question 2
A
Intuition is part of the clinical judgement the nurse is using in this situation. In making a clinical judgement, the nurse considers the context of the situation and relies on analytical processes, in-tuition, and narrative thinking. As the nurse reflects on actions taken, clinical learning occurs, which contributes to future clinical judgements.
Reflection is the process of purposefully thinking back or recalling a situation to discover its purpose or meaning.
Knowledge of the nurse includes information and theory from the basic sciences, humanities, behavioural sciences, and nursing.
Scientific method is an approach to seeking the truth or verifying that a set of facts agrees with reality.
Measuring Patient Height
Examples of NANDA nursing diagnosis
Nursing history for musculoskeletal assessment
Foley catheter with balloon in the bladder of a male patient.
Calipers being used to measure body fat on the triceps of a patient.
A therapist assisting an amputee patient to regain mobility and strength after amputation.