A patient admitted with vomiting has dry mucous membranes, poor skin turgor and a weak pulse. Which nursing diagnosis best reflects these assessment findings?
Correct answer: A. Deficient fluid volume related to fluid loss
- A. Deficient fluid volume related to fluid loss
- B. Acute gastroenteritis caused by infection
- C. Impaired oral mucous membrane related to fever
- D. Risk for imbalanced nutrition related to vomiting
Explanation
Dry mucous membranes, poor skin turgor and a weak pulse support an actual fluid volume deficit related to vomiting. Gastroenteritis is a medical diagnosis, and a risk diagnosis is less appropriate when signs of an existing problem are present.
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About Nursing Process and Health Assessment
Assessment gathers subjective and objective data through health history, physical examination and observation. The nursing process then uses nursing diagnoses, planning, implementation and evaluation to provide individualised care, while distinguishing a nursing diagnosis from a medical diagnosis and identifying priorities such as airway, breathing, circulation and safety.
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