Nokea
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. The NANDA-I (North American Nursing Diagnosis Association International) approved diagnosis must meet specific criteria related to patient assessment data, defining characteristics, and related factors. Acute pain is a well-defined nursing diagnosis with specific defining characteristics and related factors, making it a suitable and approved option for inclusion in a patient's care plan. Sore throat, sleep apnea, and heart failure do not meet the criteria for a NANDA-I approved diagnosis as they lack the specificity and comprehensive assessment data required for a nursing diagnosis.
You may also like to solve these questions
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.
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. The rationale is that NANDA-I (North American Nursing Diagnosis Association-International) approves nursing diagnoses that are specific, measurable, and relevant to nursing care. Acute pain fits these criteria as it is a common nursing diagnosis that can be assessed objectively and treated with nursing interventions. The other choices (sore throat, sleep apnea, heart failure) are medical diagnoses that do not fall under the scope of nursing diagnoses approved by NANDA-I. Therefore, acute pain is the most appropriate diagnosis to be documented in a patient's care plan according to NANDA-I guidelines.
The ff are the tonometer measurements of five clients. Which of them has normal intraocular pressure (IOP)? Choose all that apply
- A. 8 mm Hg
- B. 25 mm Hg
- C. 11 mm Hg
- D. 28 mm Hg
Correct Answer: C
Rationale: The normal range for intraocular pressure (IOP) is approximately 10-21 mm Hg. Choice C has an IOP of 11 mm Hg, falling within this normal range, making it the correct answer. Choices A, B, and D are outside the normal range, with A being too low and B and D being too high, indicating abnormal IOP levels. Choice A (8 mm Hg) is below the normal range, while choices B (25 mm Hg) and D (28 mm Hg) are above the normal range, therefore, they are incorrect answers.
Many neuromuscular disorders can impair respiratory function. What intervention can a home care nurse recommend to help prevent complications in patients with impaired respiratory function?
- A. Antibiotics as needed
- B. Bedrest
- C. Elevate the head of bed
- D. Suction q4h
Correct Answer: C
Rationale: The correct answer is C: Elevate the head of bed. Elevating the head of the bed helps improve lung expansion and ventilation, making it easier for patients with impaired respiratory function to breathe. This position also helps prevent aspiration and reduces the risk of respiratory complications. Antibiotics (choice A) are not indicated unless specifically prescribed for an infection. Bedrest (choice B) can lead to deconditioning and worsen respiratory function. Suctioning (choice D) every 4 hours is not necessary unless there is excessive secretions present.
Compartment syndrome is a potential complication of elbow fractures that decreases circulation to local neuromuscular structures. The nurse monitors circulation on a casted elbow because irreversible damage can develop if compartment syndrome lasts for more than:
- A. 48 hours
- B. 2 hours
- C. 12 hours
- D. 24 hours
Correct Answer: D
Rationale: The correct answer is D: 24 hours. Compartment syndrome occurs when pressure within a closed muscle compartment increases, leading to decreased circulation and potential tissue damage. Monitoring is crucial as irreversible damage can occur if left untreated. The 6 Ps (pain, pallor, pulselessness, paresthesia, paralysis, pressure) are key indicators. Waiting for 48 hours (choice A) or 12 hours (choice C) is too long and can result in severe consequences. 2 hours (choice B) is too short a timeframe to assess for irreversible damage development, making 24 hours (choice D) the most appropriate timeframe for monitoring and intervention.