Fundamentals Nursing Process 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 correct answer is C: Excess fluid volume. This patient is presenting with signs and symptoms of fluid overload, such as weight gain, pitting edema, distended neck veins, and crackles in the lungs. These indicate an excess of fluid in the body. Nursing care for this patient should focus on managing fluid balance.

A: Deficient fluid volume is incorrect because the patient is showing signs of fluid overload, not deficit.

B: Imbalanced nutrition more than body requirements is incorrect as the symptoms described are related to fluid volume, not nutrition intake.

D: Noncompliance is irrelevant to the patient's current symptoms and does not address the underlying issue of fluid overload.