Author Question: Nursing diagnoses meet specific criteria so they accurately reflect both the client's problem and ... (Read 59 times)

kaid0807 · **on:** Jul 22, 2018

Nursing diagnoses meet specific criteria so they accurately reflect both the client's problem and the possible etiology involved. Which one of the following statements is an example of an ap-propriately written nursing diagnosis?

a. Acute pain related to left mastectomy
b. Impaired gas exchange related to altered blood gases
c. Anxiety related to uncertainty over surgery
d. Need for high protein diet related to alteration in nutrition

Question 2

The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe.

Which of the following should the nurse implement? (Select all that apply.) a. Close all doors.
b. Note evacuation routes.
c. Note oxygen shut-offs.
d. Await direction from the fire department.
e. Evacuate everyone from the building.
f. Review Stop, drop, and roll with the nursing staff.

jaaaaaaa · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

C
The nursing diagnosis Anxiety related to uncertainty over surgery is written correctly. It defines a problem and its possible cause; in this case, the problem is anxiety related to uncertainty over surgery. The nurse can provide detailed instructions on the surgical procedure, recovery process, and postoperative care activities.
A medical diagnosis should not be recorded as an etiology because nursing interventions cannot change the medical diagnosis. It would be appropriate to state Acute pain related to impaired skin integrity secondary to mastectomy incision.
The nursing diagnosis Impaired gas exchange related to altered blood gases is written incor-rectly because it uses supportive data of the problem as an etiology.
The nursing diagnosis Need for high protein diet related to alteration in nutrition does not identify the problem and etiology. It identifies the client's goal rather than the problem. It could be reworded as Imbalanced nutrition: less than body requirements related to inadequate protein intake.

Answer to Question 2

A, B, C, D
Closing all doors helps to contain smoke and fire. Noting the evacuation routes and oxygen shut-offs is important in case the direction to evacuate comes from established channels. Evacuation from the building is determined by the established chain of command or the fire department. Evacuation is done only when necessary. Review of stop, drop, and roll, although important, is not a priority at this time.