A patient is admitted to the emergency room after experiencing severe chest pain and difficulty in taking deep breaths. The patient anxiously tells the nurse, "My father died suddenly of a heart attack at the age of 52. I'm so scared."

Question

Which nursing diagnoses are appropriate for this situation? (Select all that apply.)
a.
Acute pain
b.
Fear
c.
Risk for aspiration
d.
Risk for infection

Answer 1

ANS: A, B
One patient may have several problems simultaneously, requiring the nurse to understand the potential relatedness of signs and symptoms from various body systems. The nurse combines an understanding of pathophysiology, normal structure and function, disease processes, and symptomatology to accurately cluster data. The patient is reporting severe chest pain with an inability to take deep breaths. The nursing diagnostic label of acute pain is appropriate. Being scared is a defining characteristic of the nursing diagnosis of fear. The patient is not at risk for aspiration or infection based on the data presented.