Podcast
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)
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)
What is the "related to" data to complete the nursing diagnostic statement for Mr.Johnson's plan of care regarding acute pain?
What is the "related to" data to complete the nursing diagnostic statement for Mr.Johnson's plan of care regarding acute pain?
Hypokalemia
Which need according to Maslow supports the nursing diagnosis of Pain as a priority?
Which need according to Maslow supports the nursing diagnosis of Pain as a priority?
Physiological
Match Mr.Johnson's assessment data with the nursing diagnosis that it supports:
Match Mr.Johnson's assessment data with the nursing diagnosis that it supports:
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Match each goal statement for Mr.Johnson's plan of care with its corresponding electrolyte level:
Match each goal statement for Mr.Johnson's plan of care with its corresponding electrolyte level:
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Match each nursing diagnosis in Mr.Johnson's care plan with an accurate NOC indicator:
Match each nursing diagnosis in Mr.Johnson's care plan with an accurate NOC indicator:
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Which is an accurate goal that the nurse should include for the new nursing diagnosis of Risk for impaired skin integrity?
Which is an accurate goal that the nurse should include for the new nursing diagnosis of Risk for impaired skin integrity?
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Which indicators should the nurse monitor for the NOC of Electrolyte and acid-base balance? (Select all that apply)
Which indicators should the nurse monitor for the NOC of Electrolyte and acid-base balance? (Select all that apply)
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Which findings on the nursing assessment may be associated with hypokalemia? (Select all that apply)
Which findings on the nursing assessment may be associated with hypokalemia? (Select all that apply)
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Which electrolyte imbalance should the nurse use as the "as evidenced by" portion for the nursing diagnostic statement of Imbalanced nutrition?
Which electrolyte imbalance should the nurse use as the "as evidenced by" portion for the nursing diagnostic statement of Imbalanced nutrition?
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Which nursing diagnosis should the nurse include in the updated plan of care for a patient with edema and shortness of breath?
Which nursing diagnosis should the nurse include in the updated plan of care for a patient with edema and shortness of breath?
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What is an accurate goal statement for a patient experiencing nausea, vomiting, and diarrhea?
What is an accurate goal statement for a patient experiencing nausea, vomiting, and diarrhea?
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Which goal should the nurse include for a patient whose priority nursing diagnosis is Acute pain related to electrolyte imbalances?
Which goal should the nurse include for a patient whose priority nursing diagnosis is Acute pain related to electrolyte imbalances?
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Which indicators should the nurse monitor to determine the effectiveness of the current plan of care for Decreased cardiac output related to electrolyte imbalance?
Which indicators should the nurse monitor to determine the effectiveness of the current plan of care for Decreased cardiac output related to electrolyte imbalance?
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Study Notes
Nursing Diagnoses Related to Electrolyte Imbalances
- Risk for Electrolyte Imbalance Factors: Diarrhea, emesis, and diuretic use are key contributors to electrolyte imbalances.
- Acute Pain Related to Electrolyte Imbalances: Hypokalemia is identified as the "related to" factor in Mr. Johnson’s acute pain due to muscle cramps.
- Maslow's Hierarchy: Pain is categorized under physiological needs, making it a priority in care.
Assessment and Nursing Diagnoses
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Matching Assessment Data:
- Acute pain is linked to muscle cramps.
- Imbalanced nutrition results from hypokalemia.
- Risk for decreased cardiac output is indicated by altered cardiac rhythm.
- Goal Statements for Electrolyte Levels: Establish goals for serum sodium (135-145 mEq/L), potassium (3.5-5.0 mEq/L), calcium (8.4-10.2 mg/dL), and magnesium (1.5-2.0 mEq/L) within 48 hours.
Nursing Outcomes Classification (NOC)
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Indicators:
- Decreased cardiac output is monitored through heart rate and rhythm.
- Electrolyte imbalance is evaluated using serum potassium levels.
- Imbalanced nutrition is assessed via food and fluid intake.
- Acute pain measurement involves using comfort level assessment scales.
Caring for Patients with Skin Integrity Issues
- Risk for Impaired Skin Integrity: An accurate goal includes patients reporting pain or altered sensations in at-risk areas promptly.
Monitoring Electrolyte Imbalances
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NOC Indicators for Electrolyte Balance:
- Monitor apical heart rate and rhythm, as well as serum potassium levels for signs of electrolyte balance.
- Associated Findings of Hypokalemia: Bradycardia, poor muscle tone, and poor skin turgor are symptoms related to low potassium levels.
Nutrition and Electrolyte Imbalances
- Nutritional Assessment: If imbalanced nutrition is in the care plan due to anorexia, nausea, and vomiting, hypercalcemia should be considered as part of the assessment.
Nursing Diagnosis for Fluid Overload
- Fluid Volume Excess: Indicated by shortness of breath and edema due to electrolyte imbalances.
Goal Setting for Patient Care
- Goals for Electrolyte Levels: Aim for normal serum potassium during hospitalization for patients at risk for electrolyte imbalance.
- Pain Management Goals: Focus on achieving reduced muscle cramp pain ratings within an hour of implementing treatment.
Indicators for Cardiac Effectiveness
- Monitoring for Decreased Cardiac Output: Blood pressure and heart sounds should be regularly checked to assess treatment effectiveness for electrolyte imbalance.
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Description
This quiz focuses on nursing diagnoses related to electrolyte imbalances, particularly assessing factors that contribute to the risk of imbalances. Participants will learn to identify relevant assessment data such as diarrhea, emesis, and diuretic use that are crucial for planning effective nursing interventions.
