A premature infant never seems to sleep longer than an hour at a time. Each time a light is turned on, an incubator closes, or people talk near her crib, she wakes up and cries inconsolably until held
The correct nursing diagnosis is ineffective coping related to a. Severe immaturity
b. Environmental stress
c. Physiologic distress
d. Behavioral responses
B
Feedback
A Although the infant may be severely immature in this case she is responding to
environmental stress.
B This nursing diagnosis is the most appropriate for this infant. Light and sound
are known adverse stimuli that add to an already stressed premature infant. The
nurse must monitor the environment closely for sources of overstimulation.
C Physiologic distress is the response to environmental stress. The result is stress
cues such as increased metabolic rate, increased oxygen and caloric use and
depression of the immune system.
D The infant's behavioral response in the case is crying. The nursing diagnosis
should reflect the cause of this response, which is environmental stress.
You might also like to view...
The nurse is caring for a client with a history of chronic urinary tract infections. The nurse is planning care for this client based on the priority nursing diagnosis of urinary retention related to scaring
Based on this data, which prescription does the nurse anticipate from the healthcare provider? A) Antibiotic therapy B) An anticholinergic medication C) Intermittent straight catheterization D) Removal of bladder stones
When a nurse encounters a problem, it is best to follow the chain of command. Problems can best be resolved by:
a. agreement. b. argument. c. communication. d. withdrawing.
The nurse is completing an assessment of an older patient's oral cavity. Which finding is considered normal because of the aging process?
1. Leukoplakia 2. Gum recession 3. Increased saliva 4. Thickening tooth enamel
A patient has been diagnosed with chlamydia. Which statement by the patient would the nurse evaluate as indicating that the goal of expedited partner therapy (EPT) has been met?
1. "My boyfriend has made an appointment to get his medication.". 2. "I talked to my boyfriend about what we need to do to prevent reinfection.". 3. "I cannot convince my boyfriend to come to the clinic to learn about chlamydia.". 4. "Once I have completed treatment, my boyfriend will start taking the medication.".