The patient weighs 450 lbs (204.5 kg) and complains of shortness of breath with any exertion
His health care provider has recommended that he begin an exercise program. He states that he can hardly get out of bed and just cannot do anything around the house. To focus on the cause of the patient's complaints, the nurse devises which of the following nursing diagnoses?
a. Activity intolerance related to excessive weight
b. Activity intolerance related to bed rest
c. Impaired gas exchange related to shortness of breath
d. Imbalanced nutrition: less than body requirements
ANS: A
The diagnostic label directs nursing interventions. This requires the correct selection of related factors. For example, Activity intolerance related to excess weight gain requires very different interventions than if the related factor is prolonged bed rest. In this case, the intolerance is related to the patient's excessive weight. He is not on bed rest, although he claims that it is difficult for him to get out of bed. Shortness of breath is a symptom, not a cause, of Impaired gas exchange, making this nursing diagnosis ineffective. The patient certainly has an imbalance of nutrition, but it is more than body requirements.
You might also like to view...
The patient taking furosemide (Lasix) to correct excess edema shows a weight loss of 5.5 pounds in 24 hours. The nurse calculates this weight loss to be the excretion of approximately _____ li-ters of fluid
a. 1.0 b. 1.5 c. 2.0 d. 2.5
To palpate the thyroid gland, the isthmus of the thyroid is located. The isthmus is located directly below the:
A) Thyroid cartilage. B) Hyoid bone. C) Cricoid cartilage. D) Tracheal rings.
Choose the best description of the health care framework of paternalism
A) The physician holds the role of the father, the nurse is the mother, and the client is the child. B) The client and health care professional share in determining the options and selecting the best choice for that person. C) The balance of authority in decision making shifts away from the provider to the user of health care services, and the client is clearly in control of choices among available options. D) Interventions depend on the ability of the community health nurse to relinquish decision-making control to the community client and to trust its ability to make responsible decisions.
What limitations did the commentary highlight in the above recommendation?
What will be an ideal response?