NU 112 Nursing Diagnosis: Electrolyte Imbalances

Questions and Answers

Which assessment data should the nurse use in the 'related to' portion of the nursing diagnostic statement for Risk for electrolyte imbalance? (Select all that apply)

Cardiac arrhythmia

Emesis (correct)

Muscle cramps

Diuretic use (correct)

Diarrhea (correct)

What is the 'related to' data to complete the nursing diagnostic statement for Mr. Johnson's plan of care?

Hypokalemia

According to Maslow, which need supports the nursing diagnosis of Pain?

Physiological

Match Mr. Johnson's assessment data with the nursing diagnosis that it supports:

Acute pain = Muscle cramps Imbalanced nutrition: Less than body requirements = Hypokalemia Risk for decreased cardiac output = Altered cardiac rhythm Risk for electrolyte imbalance = Vomiting and diarrhea Signup and view all the answers

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. = 135-145 mEq/L Patient's serum K level will be within normal limits within 48 hours. = 3.5-5.0 mEq/L Patient's serum Ca level will be within normal limits within 48 hours. = 8.4-10.2 mg/dL Patient's serum Mg level will be within normal limits within 48 hours. = 1.5-2.0 mEq/L Signup and view all the answers

Match each nursing diagnosis in Mr. Johnson's care plan with an accurate NOC indicator:

Decreased cardiac output related to electrolyte imbalance = Heart rate and rhythm Risk for electrolyte imbalance related to diarrhea, vomiting, loop diuretic = Serum potassium Risk for imbalanced nutrition: less than body requirements = Food and fluid intake Acute pain related to electrolyte imbalances = Comfort level assessment scale Signup and view all the answers

Which is an accurate goal that the nurse should include for the new nursing diagnosis of Risk for impaired skin integrity?

Patient will report altered sensation or pain at risk areas as soon as noted. Signup and view all the answers

Which indicators should the nurse monitor to determine if the NOC of Electrolyte and acid-base balance has been achieved? (Select all that apply)

Serum potassium Signup and view all the answers

Which findings on the nursing assessment may be associated with hypokalemia? (Select all that apply)

Bradycardia Signup and view all the answers

Which electrolyte imbalance should the nurse use as the 'as evidenced by' portion for the nursing diagnostic statement of Imbalanced nutrition: less than body requirements?

Hyperkalemia Signup and view all the answers

Which nursing diagnosis should the nurse include in the updated patient plan of care for a patient with edema and shortness of breath?

Fluid volume excess related to electrolyte imbalances, as evidenced by edema and shortness of breath Signup and view all the answers

What is an accurate goal statement for a patient with Risk for electrolyte imbalance experiencing nausea, vomiting, and diarrhea?

Patient's serum potassium level will be within the normal range of 3.5-5.0 mEq/L during the hospitalization. Signup and view all the answers

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?

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. Signup and view all the answers

Which indicators should the nurse monitor to determine the effectiveness of the current plan of care for Decreased cardiac output related to electrolyte imbalance?

Blood pressure, heart sounds Signup and view all the answers

Study Notes

Nursing Diagnoses and Electrolyte Imbalances

Assess for related factors in nursing diagnoses of Risk for electrolyte imbalance including diarrhea, emesis, and diuretic use.
Muscle cramps and cardiac arrhythmias are symptoms but not direct related factors for electrolyte imbalance.

Patient-Specific Assessment

Acute pain in Mr. Johnson is evidenced by muscle cramps and directly linked to hypokalemia (potassium level of 2.8 mEq/L).
Confirm normal serum levels of calcium and sodium to rule out hypocalcemia and hyponatremia as causative factors.

Maslow's Hierarchy of Needs

Acute pain qualifies as a physiological need, making it a priority according to Maslow's hierarchy.

Matching Assessment Data to Nursing Diagnoses

Acute pain correlates with muscle cramps.
Imbalanced nutrition relates to hypokalemia.
Risk for decreased cardiac output is linked to altered cardiac rhythm.
Risk for electrolyte imbalance corresponds to vomiting and diarrhea.

Goal Statements for Patient Care

Serum sodium should reach normal levels (135-145 mEq/L) within 48 hours.
Serum potassium normal levels should be established (3.5-5.0 mEq/L) within 48 hours.
Serum calcium and magnesium levels should also normalize within designated time frames.

Nursing Diagnosis Indicators

For decreased cardiac output, monitor heart rate and rhythm.
For risk of electrolyte imbalance, track serum potassium levels.
For imbalanced nutrition, evaluate food and fluid intake.
For acute pain, assess comfort levels using a comfort assessment scale.

Goals for New Nursing Diagnoses

Establish a goal for the patient to promptly report any altered sensations or pain in risk areas.
Goals should be specific, measurable, and time-bound for effective nursing interventions.

Monitoring for Electrolyte Imbalances

Focus on assessing apical heart rate and rhythm to monitor electrolyte balance.
Serum potassium levels are critical indicators for managing electrolyte and acid-base balance.

Associated Findings with Hypokalemia

Hypokalemia can result in bradycardia, poor muscle tone, and poor skin turgor.
It is not associated with hypertension or increased blood glucose levels.

Nursing Diagnoses for Imbalanced Nutrition

Use hyperkalemia as the "as evidenced by" portion for Imbalanced nutrition due to anorexia, nausea, and vomiting.

Patient Care in Fluid Management

Fluid volume excess may be indicated by edema and shortness of breath; include appropriate nursing diagnoses in the care plan.

Goals for Risk of Electrolyte Imbalance

Patient's serum potassium levels should be stabilized within the normal range of 3.5-5.0 mEq/L throughout hospitalization.

Goals for Acute Pain Management

Aiming for a muscle cramp pain rating of no more than 3 on a numeric scale within one hour after treatment initiation is key.

NOC Indicators Monitoring

For patients with decreased cardiac output related to electrolyte imbalance, blood pressure and heart sounds should be routinely assessed to gauge the effectiveness of care plans.

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Description

This quiz focuses on assessing data relevant to nursing diagnoses related to electrolyte imbalances. It tests the understanding of various factors that contribute to the risk of electrolyte imbalance, including diarrhea, emesis, and diuretic use. Perfect for nursing students in NU 112 to reinforce their knowledge.