A client just had a baby following a long labor and difficult delivery. Which of the following nursing diagnoses is formulated correctly?

1. Constipation, due to tissue trauma, manifested by no bowel movement for 2 days
2. Risk for infection, because of new incision, related to episiotomy
3. Ineffective breast-feeding, related to lack of motivation, secondary to exhaustion
4. Altered urinary elimination, secondary to childbirth


Correct Answer: 3
Rationale 1: Manifested is not appropriate wording of the NANDA statement.
Rationale 2: Because of is not appropriate wording of the NANDA statement.
Rationale 3: The problem statement is listed first (NANDA label), followed by the etiology–factors that contribute to or are the cause of the client's response. The two parts are joined by the words related to, implying a relationship between the two. Adding a second part to the etiology statement makes it more descriptive and useful.
Rationale 4: The problem statement is listed first (NANDA label), followed by the etiology–factors that contribute to or are the cause of the client's response – lacking in this option.

Nursing

You might also like to view...

All of the following contribute to disturbed or interrupted sleep except

a. Alcohol b. Activity c. Sedentary lifestyle d. Tobacco

Nursing

An infant hospitalized with multiple fractures has just been diagnosed with osteogenesis imperfecta. The nurse finds the parents crying. Which response by the nurse is the most appropriate?

A. "I know how you feel. I would be upset to find this out too." B. "There is medicine that can allow her to live a normal life." C. "Would you like me to help you with holding your baby?" D. "You are actually lucky; many of these babies die at birth."

Nursing

Why will the nurse monitor the SVO2 in a patient with septic shock?

1. A SvO2 of 65% shows that the oxygen demand of tissues exceeds the oxygen supply. 2. A SvO2 of 95% or above shows normal oxygen supply and demand. 3. A SvO2 of 70% is adequate to deliver oxygen to body organs and tissues. 4. A decrease in the SvO2 shows that more oxygen is returning to the lungs before being metabolized.

Nursing

A nurse working on a PICO question has found a large amount of literature available on the topic that she is interested in. There have been multiple studies that have been published

Which of the following types of studies should have the best evidence? A. Meta-analysis of randomized control trials B. Opinion of an expert committee C. One well-designed randomized control trial D. Systematic review of descriptive and qualitative studies

Nursing