The nurse is writing the care plan for a patient admitted to the hospital for complications associated with muscular dystrophy. Which nursing diagnoses written on the care plan indicate a need for further instruction in constructing the diagnostic stateme
a. Constipation related to immobility as manifested by lower extremity weakness.
b. Activity intolerance related to weakness as evidenced by verbal report of fatigue.
c. Feeding self-care deficit related to fatigue as manifested by inability to swallow food.
d. Ineffective airway clearance related to muscle weakness.
ANS: D
Each type of nursing diagnostic statement contains sections or parts. Actual nursing diagnostic statements are written with three parts: a diagnosis label, related factors, and defining characteristics. Risk nursing diagnoses have two segments: a diagnosis label and risk factors. Health-promotion nursing diagnoses are written with only two sections: the diagnosis label and defining characteristics. The ineffective airway clearance label is missing the defining characteristics.
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