Author Question: A nursing diagnosis of Risk for Deficient Fluid Volume related to excessive fluid loss, secondary to ... (Read 93 times)

wrbasek0 · **on:** Jul 23, 2018

A nursing diagnosis of Risk for Deficient Fluid Volume related to excessive fluid loss, secondary to diarrhea and vomiting was implemented for a home health client who began with these symptoms 5 days ago.

A goal was that the client's symptoms would be eliminated within 48 hours. The client is being seen after a week, and has had no diarrhea or vomiting for the past 5 days. The nurse should:
1. Keep the problem on the care plan, in case the symptoms return.
2. Document that the problem has been resolved and discontinue the care for the problem.
3. Assume that whatever the cause was, the symptoms may return, but document that the goal was met.
4. Document that the potential problem is being prevented since the symptoms have stopped.

Question 2

The written goal statement in a client's care plan is: Client will have clear lung sounds bilaterally within 3 days.

One of the interventions to meet this goal is that the nurse will teach the client to cough and deep breathe and have the client do this several times every 2 hours. At the end of the third day, the client's lungs are indeed clear. In order to relate the intervention to the outcome, the nurse should:
1. Ask how many times per day the client practiced the coughing and deep breathing exercises.
2. Tell the client that the lungs are clear.
3. Document the assessment findings to show the effectiveness of the intervention.
4. Write this evaluation statement: Goal met, lung sounds clear by third day.

todom5090 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 2
Rationale: In this case, the risk factors no longer exist because the causative factors have stopped. The nurse should document that the goal has been met and discontinue the care for the problem. If the problem returns, it can be implemented again and addressed at that time.

Answer to Question 2

Correct Answer: 1
Rationale 1: Part of the evaluating process is determining whether the nursing activities had any relation to the outcomes. Did the lungs clear because the client actually did the coughing and deep breathing? In order to know for sure, the nurse must collect more data and not assume that this particular nursing intervention had any relation to the outcome.
Rationale 2: Telling the client that his/her lungs are clear is not evrelating intervention to outcome since no mention of the intervention is made.
Rationale 3: Documenting does not show effectiveness of the intervention.
Rationale 4: Writing an evaluation statement does not show effectiveness of the intervention.