NCLEX RN Pediatric Questions Related

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A patient is admitted with symptoms of a recent weight gain, 3+ pitting edema of his feet, distended neck veins, and crackles in his lungs. Which of the following nursing diagnoses is most appropriate for this patient's plan of care?

  • A. Deficient fluid volume
  • B. Imbalanced nutrition more than body requirements
  • C. Excess fluid volume
  • D. Noncompliance
Correct Answer: C

Rationale: The patient's symptoms of recent weight gain, 3+ pitting edema of his feet, distended neck veins, and crackles in his lungs are indicative of fluid volume excess. These signs and symptoms suggest that the patient is retaining too much fluid, leading to the edema and congestion in the lungs. The nursing diagnosis of Excess Fluid Volume is appropriate for this patient as it reflects the patient's current physiological state and guides the plan of care to address excess fluid accumulation through interventions such as diuretic therapy, fluid restriction, and monitoring of intake and output. Deficient fluid volume, Imbalanced nutrition more than body requirements, and Noncompliance are not appropriate nursing diagnoses given the patient's presentation of fluid overload.