The patient reports being tired and weak and lacks energy. Upon assessment, the nurse finds that patient has gained weight, and blood pressure and pulse are elevated after climbing stairs. Which nursing diagnosis will the nurse add to the care plan?
a. Fatigue
b. Ineffective coping
c. Activity intolerance
d. Decreased cardiac output
ANS: C
You consider nursing diagnoses of Activity intolerance or Fatigue in a patient who reports being tired and weak. Further review of assessed defining characteristics (e.g., abnormal heart rate and verbal report of weakness and the assessment findings occurring during the activity of climbing the stairs) leads to the definitive diagnosis (Activity intolerance). There is no data to support ineffective coping or decreased cardiac output.
You might also like to view...
Causes associated with the diagnosis status epilepticus include (Select all that apply.)
a. high fever. b. encephalitis. c. metabolic disorder. d. meningitis. e. gradual weaning of anticonvulsant drugs.
The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to
a. connect the recorder to a computer once daily. b. exercise more than usual while the monitor is in place. c. remove the electrodes when taking a shower or tub bath. d. keep a diary of daily activities while the monitor is worn.
The feelings of helplessness, discomfort, and disorientation experienced by an individual attempting to understand or effectively adapt to a different cultural group because of differ-ences in practice, values, and beliefs is called:
1. Ethnocentrism 2. Cultural conflict 3. Cultural imposition 4. Cultural shock
Community-based nursing intervenes
A) in self-care. B) at the primary level of prevention. C) at all three levels of prevention. D) in disease management.