A charge nurse is evaluating a new nurse's plan of care. Which ...

[ssal]

A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge nurse to follow up?
 
  a. Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous (IV) antibiotics
  b. Completing an interview and physical examination before adding a nursing diagnosis
  c. Developing nursing diagnoses before completing the database
  d. Including cultural and religious preferences in the database

Question 2

A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. The nurse analyzes the data. Which nursing diagnosis will the nurse assign to the patient?
 
  a. Adult failure to thrive
  b. Hypothermia
  c. Deficient fluid volume
  d. Nausea

[akpaschal]

Answer to Question 1

ANS: C
Developing nursing diagnoses before completion of the database needs to be corrected by the charge nurse. Always identify a nursing diagnosis from the data, not the reverse. The data should be clustered and reviewed to see if any patterns are present before a nursing diagnosis is assigned. Risk for infection is an appropriate diagnosis for a patient with an intravenous (IV) site in place. The IV site involves a break in skin integrity and is a potential source of infection. The diagnostic process should proceed in steps. Completing the interview and physical examination before adding a nursing diagnosis is appropriate. The patient's cultural background and developmental stage are important to include in a patient database.

Answer to Question 2

ANS: C
The signs the patient is exhibiting are consistent with deficient fluid volume (dehydration). Even without knowing the clinical manifestations of dehydration, the question can be answered by the process of elimination. Adult failure to thrive, hypothermia, and nausea are not appropriate diagnoses because data are insufficient to support these diagnoses.