Nursing diagnoses meet specific criteria so they accurately reflect both the client's problem and the possible etiology involved. Which one of the following statements is an example of an ap-propriately written nursing diagnosis?
a. Acute pain related to left mastectomy
b. Impaired gas exchange related to altered blood gases
c. Anxiety related to uncertainty over surgery
d. Need for high protein diet related to alteration in nutrition
C
The nursing diagnosis "Anxiety related to uncertainty over surgery" is written correctly. It defines a problem and its possible cause; in this case, the problem is anxiety related to uncertainty over surgery. The nurse can provide detailed instructions on the surgical procedure, recovery process, and postoperative care activities.
A medical diagnosis should not be recorded as an etiology because nursing interventions cannot change the medical diagnosis. It would be appropriate to state Acute pain related to impaired skin integrity secondary to mastectomy incision.
The nursing diagnosis "Impaired gas exchange related to altered blood gases" is written incor-rectly because it uses supportive data of the problem as an etiology.
The nursing diagnosis "Need for high protein diet related to alteration in nutrition" does not identify the problem and etiology. It identifies the client's goal rather than the problem. It could be reworded as Imbalanced nutrition: less than body requirements related to inadequate protein intake.
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The nurse is explaining factors that affect an individual's body alignment, mobility, and daily activity level. Examples of client factors that might decrease mobility and activity include: Standard Text: Select all that apply
1. Vestibular disorder. 2. Spina bifida. 3. Anemia. 4. Overnutrition. 5. Ear canal infection.
You are caring for a middle-aged woman who is suffering from major depression and melancholia. She expresses her "failure as a wife and mother" and that she "deserves to die." Your first priority to this patient is to:
A) Reassure her that she is a very good wife and mother B) Tell her that her illness is not a punishment and she does not deserve to die C) Divert her to other activities to get her mind off herself D) Protect and monitor her for suicidal tendencies
When caring for a patient who has an abductor wedge in place after a total hip replacement, for which finding should the nurse assess?
a. Muscle spasms b. Alteration in peripheral circulation c. Compression fracture d. Appropriateness of the size of the wedge
A pregnant client who uses cocaine and ecstasy on a regular basis asks why ecstasy should not be used during pregnancy. What should the nurse explain about this drug?
1. "It produces intrauterine growth restriction and meconium aspiration." 2. "It leads to deficiencies of thiamine and folic acid, which help the baby develop." 3. "It produces babies with small heads and short bodies with brain function alterations." 4. "It can cause a high fever in you if high doses are taken and therefore cause the baby harm."