vSim Health Assessment Case 10: Rashid Ahmed
A patient is admitted reporting diarrhea, nausea, vomiting, dizziness, and abdominal pain. Diagnoses of hypokalemia, dehydration, and gastroenteritis are pending. Intravenous access has been established for this patient. Which nursing intervention has priority considering the patient's symptoms and expected diagnoses?
Administering potassium chloride in a timely, effective manner Rationale: Hypokalemia, a condition characterized by insufficient potassium levels, places the patient at risk for a variety of health concerns, including cardiac arrhythmia and arrest. Managing this condition is a priority. Remediation: Lippincott Advisor: Drugs: Potassium chloride
A patient being admitted to a medical unit is receiving a general assessment by the nurse. What is the priority action for the nurse to take when the patient says, "I've been so nauseous"?
Conduct a focused assessment of the patient's abdomen Rationale: When an abnormality or concern is identified, the nurse will need to perform an in-depth focused assessment on the body area that appears to be affected, in this case the abdomen. The remaining options do not have priority over the abdominal assessment. Remediation: Weber and Kelley, Health Assessment in Nursing, 6th Edition, pp. 121-122
An older adult diagnosed with gastroenteritis has an admission potassium level of 2.9 mEq/L. Of the following admission orders, which has initial priority for the nurse caring for this patient?
Insert saline lock Rationale: This patient's potassium level is below the normal range of 3.5 to 5 mEq/L (hypokalemia), so the patient is in danger of experiencing cardiac complications such as arrhythmias or arrest. The establishment of intravenous access is necessary for the administration of potassium to elevate the electrolyte level back to within the normal range. Hypokalemia can cause bradycardia, not tachycardia. The remaining options are appropriate but do not have priority over initiating the steps necessary to introduce potassium into the vascular system of this patient. Remediation: Lippincott Advisor, Diseases and Conditions: Hypokalemia
Mr. Ahmed's diagnosis of gastroenteritis has been treated with antibiotic therapy. Which assessment data best supports the effectiveness of this therapy?
Oral temperature is 36.6°C (97.8°F) Rationale: Effective antibiotic therapy would result in an absence of fever. The other options are not as directly associated with infection control but rather dehydration. Remediation: Lippincott Advisor, Diseases and Conditions: Gastroenteritis
Which reaction requires immediate notification of the health care provider when a patient is receiving the antibiotic ciprofloxacin?
Numbness in any extremity Rationale: Peripheral neuropathy may develop from ciprofloxacin therapy and must be reported to the health care provider. The other symptoms are not generally associated with administration of this medication. Remediation: Lippincott Advisor, Drugs: Ciprofloxacin
A patient has been treated for diarrhea and vomiting, which has caused dehydration and hypokalemia. Which assessment data will confirm that the IV administration of potassium has been effective?
-Heart rate is 86 beats per minute, with regular rhythm Rationale: IV fluid and potassium administration is appropriate for this patient. Hypokalemia can result in cardiac dysrhythmias and even cardiac arrest. Effective treatment would demonstrate a pulse that is normal in rate (60 to100 beats per minute), rhythm, and strength. The remaining options suggest that dehydration is resolved, but are not indications that the hypokalemia is resolved. Remediation: Lippincott Adviser, Diseases and Conditions: Hypokalemia
An older adult patient being treated for gastroenteritis-induced dehydration and hypokalemia is now being assessed for discharge. Which assessment findings will confirm the effectiveness of the treatment? (Select all that apply.) 24-hour fluid intake is 1700 mL, and fluid output is 1950 mL Serum potassium level is 3.2 mEq/L Mucous membranes appear moist Patient reports abdominal pain as 1 out of 10 Patient has one semi-formed stool in the last 12 hours
-24-hour fluid intake is 1700 mL, and fluid output is 1950 mL , -Mucous membranes appear moist , -Patient reports abdominal pain as 1 out of 10 , -Patient has one semi-formed stool in the last 12 hours Rationale: The loss of body fluids associated with gastroenteritis can trigger both dehydration and hypokalemia. As a result, mucous membranes become dry, urine output and fluid intake drop, frequent diarrhea occurs, and abdominal pain is present. Improvement or elimination of these signs and symptoms demonstrate an effective plan of care. Potassium levels drop as a result of vomiting and diarrhea. A level within the normal range, between 3.5 and 5 mEq/L, would indicate successful resolution of hypokalemia. Remediation: Lippincott Advisor, Nursing Diagnosis Care Plans: Risk for deficient fluid volume
Mr. Ahmed is being considered for discharge after being successfully treated for nausea, vomiting, and diarrhea associated with gastroenteritis. Which assessment data best supports the success of his treatment?
-Active bowel sounds present in all quadrants Rationale: Diarrhea, a primary sign associated with gastroenteritis, presents with hyperactive bowel sounds. Assessment data indicating normally active bowel sounds in all abdominal quadrants would indicate that the patient is responding to treatment. Antibiotic treatment is often incorporated, but toleration of the medication can be affected by a variety of administration routes. The remaining options are primarily associated with dehydration, which is a comorbid condition that can be associated with gastroenteritis. Remediation: Weber and Kelley, Health Assessment in Nursing, 6th Edition, p. 507
Mr. Ahmed has been diagnosed with gastroenteritis. Which of his assessment findings are directly associated with an improvement in this condition? (Select all that apply.) Hypoactive bowel sounds present Bowel sounds heard in all four quadrants Abdomen soft Voiding without difficulty Tolerating small amounts of clear liquids
-Bowel sounds heard in all four quadrants -Abdomen soft -Tolerating small amounts of clear liquids Rationale: Gastroenteritis is the self-limiting inflammation of the stomach and small intestine. Abdominal pain, vomiting, and diarrhea are the primary resulting symptomatology. Dehydration is a complication of gastroenteritis. Bowel sounds in all quadrants and a soft, nondistended abdomen are objective signs that indicate improvement. The ability to tolerate small amounts of liquids without experiencing nausea and vomiting is also a positive event. Voiding without difficulty is associated with the complication of dehydration, whereas hypoactive bowel sounds are not associated with either gastroenteritis or normal gastrointestinal functioning. Remediation: Lippincott Advisor, Diseases and Conditions: Gastroenteritis
Which patient statement supports that dehydration-related orthostatic hypotension is being resolved with treatment?
Now that my dizziness is gone, I feel so much safer about getting up and walking. Rationale: Dizziness associated with orthostatic hypotension can be a result of dehydration. The patient's statement concerning safer mobility indicates that the dizziness is resolving or is no longer an issue. The remaining options either relate to rehydration, effects of dehydration, or precautions taken to minimize the effects of orthostatic hypotension. Remediation: Lippincott Advisor, Signs and Symptoms: Orthostatic hypotension
A patient has been admitted for treatment of abdominal pain, nausea, and diarrhea. Which finding identified during the nursing assessment is most associated with a bacterial or viral infection?
Oral temperature of 38.1°C (100.6°F) Rationale: An elevated temperature (higher than 38.0°C or 100°F) may be seen in both viral and bacterial infections. Although the pulse and respiratory rates can be elevated as a result of a fever, all the remaining options are within normal limits. Remediation: Weber and Kelley, Health Assessment in Nursing, 6th Edition, p. 122
The nurse is preparing to conduct a head-to-toe examination on a patient being admitted with a tentative diagnosis of gastroenteritis. What equipment will the nurse require to effectively perform the portion of the physical examination directly associated with the patient's affected physical system?
Stethoscope Rationale: The system that is the focus for gastroenteritis would be the abdomen. The stethoscope would be necessary to assess bowel sounds; they would likely be hyperactive in this patient. A reflex hammer is associated with the neurologic system. Water-soluble lubricant is used in examining both the male and female genitalia and the rectum. The Doppler ultrasound is used to examine the peripheral vascular system. Remediation: Weber and Kelley, Health Assessment in Nursing, 6th Edition, p. 675
Mr. Ahmed has demonstrated improvement after treatment was implemented 48 hours ago for dehydration associated with gastroenteritis. Which discharge instruction will the nurse provide to best help resolve his original report of dizziness?
-Drink fluids every 15 to 30 minutes, increasing the amount as your tolerance improves Rationale: A common cause of dizziness associated with gastroenteritis is dehydration. Rehydrating with frequent, small amount of oral fluids will help reestablish blood volume and resolve the dizziness. While the other options are appropriate, they are not directed toward correcting the problem but rather minimizing the risk of injury or, in the case of the alcohol, preventing it from negatively affecting the treatment. Remediation: Lippincott Advisor, Lexicomp and UpToDate Patient Handouts: Dehydration Discharge Instructions, Adult
Mr. Ahmed is being considered for discharge after being successfully treated for nausea, vomiting, and diarrhea associated with gastroenteritis. Which assessment data best supports the success of his treatment?
-Drink fluids rink every 15 to 30 minutes, increasing the amount as your tolerance improves Rationale: A common cause of dizziness associated with gastroenteritis is dehydration. Rehydrating with frequent, small amount of oral fluids will help reestablish blood volume and resolve the dizziness. While the other options are appropriate, they are not directed toward correcting the problem but rather minimizing the risk of injury or, in the case of the alcohol, preventing it from negatively affecting the treatment. Remediation: Lippincott Advisor, Lexicomp and UpToDate Patient Handouts: Dehydration Discharge Instructions, Adult
A patient diagnosed with gastroenteritis has reported dizziness when standing up from a sitting position. What information will the nurse provide to the patient to best explain the need to monitor all fluid intake and urinary output?
-Dehydration may be causing your dizziness, so it's important to monitor the balance of fluids in your body. Rationale: The patient's diagnosis is characterized with vomiting and diarrhea, both of which contribute to a fluid imbalance. Orthostatic hypotension is related to such a fluid imbalance. A standard intervention is the monitoring of both intake and output to assess for possible dehydration and direct its treatment. While the remaining options are correct statements, they do not educate the patient about the cause and treatment of the problem. Remediation: Lippincott Advisor, Signs and Symptoms: Orthostatic hypotension Lippincott Procedures: Intake and output assessment
Hydration status is being monitored for a patient being treated for dehydration. Which statements made by the nurse to the patient accurately reflect the assessment of fluid intake and output? (Select all that apply.) Liquid stool and vomitus will be assessed as well as urine. Your urine will be stored in the bathroom and measured twice a shift The amount of IV fluids you receive will also be recorded as part of your fluid intake. When may I talk with your family about helping us keep track of your fluids?" Do you remember how to use the urine hat to save your urine?
Liquid stool and vomitus will be assessed as well as urine. , The amount of IV fluids you receive will also be recorded as part of your fluid intake. , When may I talk with your family about helping us keep track of your fluids?" , Do you remember how to use the urine hat to save your urine? Rationale: Fluid output includes urine, liquid stool, vomitus, blood, and drainage from tubes (such as chest tubes), ileostomies, nephrostomy tubes, suction devices, and surgical drains. IV fluids are considered when monitoring fluid intake. Urine can be collected and measured using a bedpan or a urine hat placed on the commode. The nurse should explain to the patient and the family that the nurse will be measuring intake and output, and ask for their help. Instruct the family to measure fluids that they give to the patient, to place output in a urinal or bedpan in the bathroom, and to call the nurse to have it measured. Urine is discarded after it is measured and recorded, unless it is being saved as a part of a 24-hour urine specimen. Remediation: Lippincott Procedures: Intake and output assessment
Which nursing interventions would provide appropriate support for a patient being treated for a bacterial infection? (Select all that apply.) Encouraging fluid and nutritional intake as tolerated Regularly monitoring and recording temperature Implementing seizure precautions Maintaining a cool room temperature Providing appropriate clothing and bed coverings to prevent overheating
-Encouraging fluid and nutritional intake as tolerated , -Regularly monitoring and recording temperature , -Providing appropriate clothing and bed coverings to prevent overheating Rationale: The monitoring of temperature, encouraging fluid and food intake as tolerated, and preventing overheating are all appropriate, supportive nursing measures for a patient experiencing a bacterial infection. A cool environment may encourage chills, which would serve to increase the patient's temperature. Seizures are more likely to occur in children, who experience extremely high fevers. Remediation: Lippincott Advisor, Signs and Symptoms: Fever
Which intervention is focused on assuring a patient's cooperation and minimizing the patient's concerns while gathering subjective information during an abdominal assessment? (Select all that apply.) Providing an explanation of why personal questions will be asked Gathering all necessary equipment prior to beginning the assessment Performing appropriate handwashing before touching the patient Asking questions in a matter-of-fact manner Placing the patient in a comfortable and assessable position
-Providing an explanation of why personal questions will be asked , -Asking questions in a matter-of-fact manner Rationale: Subjective information is data that can only be elicited and verified by the patient. Since the questioning can be embarrassing, the nurse should be attentive to educating the patient to why such questioning is necessary and to ask the questions in a non-biased, matter-of-fact manner. The other options are directed toward the gathering of objective data during the abdominal assessment. Remediation: Weber and Kelley, Health Assessment in Nursing, 6th Edition, pp. 495-496
The nurse is assessing a patient's abdomen during a physical assessment. What will be the focus of the nurse's inspection? (Select all that apply.) Symmetry and contour Location and contour of the umbilicus Abdominal reflex Overall skin color Aortic pulsations
-Symmetry and contour -Location and contour of the umbilicus -Overall skin color -Aortic pulsations Rationale:Inspection of the abdomen includes the following: notice of the overall skin color; location, color, and contour of the umbilicus; symmetry and contour of the abdomen; and aortic pulsations and/or peristaltic waves. Assessment of the abdominal reflex requires light palpation of the abdomen, and thus is not included in the inspection phase of the assessment. Remediation:Weber and Kelley, Health Assessment in Nursing, 6th Edition, pp. 681-682
An older patient is admitted with a diagnosis of gastroenteritis and dehydration. What assessment data documented by the nurse support this diagnosis? (Select all that apply.) Reports vomiting after taking "even a little drink of water" Reports feeling dizzy when standing up Appears flush and moist in the face Produces dark yellow urine Reports experiencing diarrhea for last 48 hours
Reports vomiting after taking "even a little drink of water" , Reports feeling dizzy when standing up , Produces dark yellow urine , Reports experiencing diarrhea for last 48 hours Rationale: Symptoms associated with dehydration include: diarrhea that has lasted a few days or longer; vomiting triggered by attempting to eat or drink; infrequent urination that produces dark yellow or brown urine; and feeling dizzy, especially when standing from a sitting or lying position. Flushed (ruddy), moist skin is not associated with dehydration. Remediation: Lippincott Advisor, Lexicomp and UpToDate Patient Handouts: Dehydration
An older patient is being treated for an infection that has resulted in a diagnosis of gastroenteritis. Which statement made by the nurse indicates an understanding of how the signs of this condition may appear in an older patient?
The normal temperature range in an older adult is lower than that of a younger adult. Rationale: Research has shown that for older adults, normal body temperature values for all routes are consistently lower than in younger adults. None of the remaining options presents a true statement. Remediation: Weber and Kelley, Health Assessment in Nursing, 6th Edition, p. 129 8Which reaction requires immediate notification of the health care provi