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Which diagnosis will the nurse document in a patient’s care plan that is NANDA-I approved?
- A. Sore throat
- B. Acute pain
- C. Sleep apnea
- D. Heart failure
Correct Answer: B
Rationale: The correct answer is B: Acute pain. NANDA-I (North American Nursing Diagnosis Association International) approves standardized nursing diagnoses to guide nursing care. Acute pain is a NANDA-I approved diagnosis as it helps identify and address a patient's pain experience. It is specific, measurable, and relevant for care planning. Sore throat (A) is a symptom, not a diagnosis. Sleep apnea (C) and heart failure (D) are medical conditions, not nursing diagnoses. The focus of nursing care plans is on identifying patient responses to health conditions, which is why acute pain is the most appropriate choice.
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The nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should:
- A. Use commercial preparations to remove
- B. Wash and inspect the feet daily
- C. Walk barefoot at least once each daily
- D. Cut the toenails by rounding edges
Correct Answer: B
Rationale: The correct answer is B: Wash and inspect the feet daily. This is important for clients with diabetes mellitus to prevent complications like foot ulcers. Daily foot care helps detect any issues early. Choice A is incorrect as it is not recommended to use commercial preparations without medical advice. Choice C is incorrect as walking barefoot can increase the risk of injury and infection. Choice D is incorrect as cutting toenails by rounding edges can lead to ingrown toenails, which can be dangerous for clients with diabetes.
After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
- A. abnormal vital signs. Have the patient transported to the radiology department for a scheduled x-ray, and
- B. review vital signs upon return.
- C. Ask the NAP to record the patient’s vital signs before administering medications.
- D. Omit the vital signs because the patient is presently in no distress.
Correct Answer: C
Rationale: The correct answer is C because it is essential for the nurse to ensure accurate and up-to-date vital signs before administering medications. By asking the NAP to record the patient's vital signs, the nurse can make informed decisions about the patient's condition and prevent any potential complications.
Choice A is incorrect because administering medications without knowing the patient's vital signs, particularly if they are abnormal, can be dangerous. Choice B is not the best course of action as it delays the crucial step of obtaining the vital signs. Choice D is incorrect as omitting vital signs without assessment could compromise patient safety. Therefore, choice C is the most appropriate response to ensure patient well-being and medication safety.
The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover:
- A. Cancerous lumps.
- B. Changes from previous self-examinations.
- C. Areas of thickness or fullness.
- D. Fibrocystic masses.
Correct Answer: A
Rationale: The correct answer is A: Cancerous lumps. Breast self-examination aims to detect any abnormal changes in the breasts, including potential cancerous lumps. Detecting cancerous lumps early increases the chances of successful treatment and improved outcomes. Choices B, C, and D are incorrect because while changes from previous self-examinations, areas of thickness or fullness, and fibrocystic masses can be important to note, the primary goal of breast self-examination is to identify any signs of breast cancer, such as cancerous lumps.
An adult is diagnosed with disseminated intravascular coagulation. The nurse should identify that the client is at risk for which of the following nursing diagnosis?
- A. Risk for increased cardiac output related to fluid volume excess
- B. Disturbed sensory perception related to bleeding into tissues
- C. Alteration in tissue perfusion related to bleeding and diminished blood flow
- D. Risk for aspiration related to constriction of the respiratory musculature
Correct Answer: C
Rationale: The correct answer is C: Alteration in tissue perfusion related to bleeding and diminished blood flow. Disseminated intravascular coagulation (DIC) is a condition where blood clots form throughout the body, leading to both bleeding and clotting. This can result in decreased blood flow to tissues, causing tissue perfusion issues.
Explanation:
1. Option A: Risk for increased cardiac output related to fluid volume excess is incorrect because DIC can lead to bleeding, causing a decrease in blood volume and potentially decreasing cardiac output.
2. Option B: Disturbed sensory perception related to bleeding into tissues is incorrect as DIC primarily affects blood clotting and bleeding, not sensory perception.
3. Option D: Risk for aspiration related to constriction of the respiratory musculature is incorrect as DIC does not directly cause constriction of respiratory muscles, but rather impacts the clotting and bleeding processes in the body.
In summary, the correct answer is C because DIC can lead to altered tissue perfusion
Which diagnosis will the nurse document in a patient’s care plan that is NANDA-I approved?
- A. Sore throat
- B. Acute pain
- C. Sleep apnea
- D. Heart failure
Correct Answer: B
Rationale: The correct answer is B: Acute pain. This is the only choice that aligns with NANDA-I approved nursing diagnoses. Acute pain is a common nursing diagnosis that focuses on addressing a patient's immediate discomfort. NANDA-I emphasizes the importance of using standardized nursing diagnoses to improve communication and ensure proper interventions. Sore throat (A) and sleep apnea (C) are symptoms or medical diagnoses, not specific nursing diagnoses. Heart failure (D) is a medical diagnosis and not a NANDA-I approved nursing diagnosis.