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Which assessment data should the nurse use in the “related to” portion of the nursing diagnostic statement for Risk for electrolyte imbalance? Choose all that apply.
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The nurse identifies acute pain as one of Mr. Johnson’s priority nursing diagnoses, which is evidenced by muscle cramps. What is the “related to” data to complete the nursing diagnostic statement for Mr. Johnson’s plan of care?
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week 12

Nursing Diagnosis and Planning Related to Electrolyte Imbalances

QuestionAnswer
Which assessment data should the nurse use in the “related to” portion of the nursing diagnostic statement for Risk for electrolyte imbalance? Choose all that apply. Diarrhea Emesis Diuretic use
The nurse identifies acute pain as one of Mr. Johnson’s priority nursing diagnoses, which is evidenced by muscle cramps. What is the “related to” data to complete the nursing diagnostic statement for Mr. Johnson’s plan of care? Hypokalemia
Mr. Johnson’s assessment data reveals hypokalemia and muscle cramping leading to a priority nursing diagnosis of Pain. Which need, according to Maslow, supports this nursing diagnosis as a priority? Physiological
Match Mr. Johnson’s assessment data with the nursing diagnosis that it supports. Acute pain Imbalanced nutrition: Less than body requirements Risk for decreased cardiac output Risk for electrolyte imbalance Muscle cramps Hypokalemia Altered cardiac rhythm Vomiting and diarrhea
Match each goal statement for Mr. Johnson’s plan of care with its corresponding electrolyte level. Patient’s serum Na level will be within normal limits within 48 hours. Patient’s serum K level will be within normal limits within 48 hours. Patient’s se 135-145 mEq/L 3.5-5.0 mEq/L 8.4 -10.2 mg/dL 1.5-2.0 mEq/L
Match each nursing diagnosis in Mr. Johnson’s care plan with an accurate NOC indicator. Decreased cardiac output related to electrolyte imbalance Risk for electrolyte imbalance related to diarrhea, vomiting, loop diuretic Risk for imbalanced nutrition: Heart rate and rhytmn Serum potassium Food and fluid intake Comfort level assessment scale
Mr. Johnson continues to exhibit poor skin turgor and reports redness and irritation to the skin. The nurse adds Risk for impaired skin integrity to the plan of care. Which is an accurate goal that the nurse should include for the new nursing diagnosis? Patient will report altered sensation or pain at risk areas as soon as noted.
One of Mr. Johnson’s nursing diagnoses is Risk for electrolyte imbalance. Which indicators should the nurse monitor to determine if the NOC of Electrolyte and acid-base balance has been achieved? Apical heart rate and rhythm Serum potassium
The nurse identifies hypokalemia in a patient. Which findings on the nursing assessment may be associated with this electrolyte imbalance? Bradycardia Hypertension Poor muscle tone Poor skin turgor
The nurse identifies the nursing diagnosis of Imbalanced nutrition: less than body requirements related to anorexia, nausea, and vomiting. Which electrolyte imbalance should the nurse use as the “as evidenced by” portion for this nursing diagnostic statem Hypercalcemia
The nurse is providing care to a patient with electrolyte imbalance showing edema and shortness of breath. Which nursing diagnosis should the nurse include in the updated patient plan of care? Fluid volume excess related to electrolyte imbalances, as evidenced by edema and shortness of breath
The nurse identifies the nursing diagnosis Risk for electrolyte imbalance for an older adult patient experiencing nausea, vomiting, and diarrhea. Which is an accurate goal statement for the nurse to include in the patient’s plan of care? Patient’s serum potassium level will be within the normal range of 3.5–5.0 mEq/L during the hospitalization.
The nurse is planning care for a patient whose nursing diagnosis is Decreased cardiac output related to electrolyte imbalance. The NOC for this nursing diagnosis is Cardiac pump effectiveness. Which indicators should the nurse monitor to determine the eff Blood pressure Heart sounds
Which goal should the nurse include in the plan of care for a patient whose priority nursing diagnosis is Acute pain related to electrolyte imbalances, as evidenced by muscle cramping? Patient will report a muscle cramp pain rating of no more than 3 on a 1 to 10 numeric scale within 1 hour of implementing prescribed treatment.
Mr. Johnson continues to exhibit poor skin turgor and reports redness and irritation to the skin. The nurse adds Risk for impaired skin integrity to the plan of care. Which is an accurate goal that the nurse should include for the new nursing diagnosis? Patient will report altered sensation or pain at risk areas as soon as noted
Created by: Brandi Sizemore
 

 



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