Author Question: The nurse is assessing a patient who is complaining of chest pain, clutching his chest, and is short ... (Read 67 times)

krzymel · **on:** Jul 23, 2018

The nurse is assessing a patient who is complaining of chest pain, clutching his chest, and is short of breath. Which assessment question would be appropriate for the nurse to ask?

a. Please describe your pain, its location, and what you've done to treat it.
b. Does the pain radiate to your arm, jaw, or shoulder?
c. What are your current medications including supplements or vitamins?
d. What is your medical history beginning with most recent?

Question 2

The nurse is developing a plan of care for a female patient who expresses loss of interest in sexual intimacy with her husband following a mastectomy several months ago. What nursing diagnosis would be most appropriate for this patient?

a. Ineffective sexuality patterns
b. Sexual Dysfunction
c. Activity Intolerance and Fatigue
d. Disturbed Body Image

smrtceo · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

B
In a situation in which breathing and/or circulation are inadequate, questions should be phrased to allow short (e.g., yes or no) answers that do not tax the patient's ability to breathe and talk. Asking the patient to describe the pain, location, and self-treatment would require an extended verbal response from a patient who is having trouble breathing. It would stress the patient to try to respond. Although a list of medications is important to determine, the patient with compromised breathing and circulation is unlikely to be able to provide this information. The patient who is having difficulty answering is unlikely to be able to supply information about past medical history, despite its importance. Asking a spouse or close relative is likely to yield a more complete reply.

Answer to Question 2

D
The patient's lack of sexual intimacy resulted following the mastectomy, so the most likely cause is the change in body image. Disturbed Body Image would be the most appropriate nursing diagnosis for this patient. If interventions help improve her body image, the sexual issues may resolve themselves. Although this patient is displaying an ineffective sexuality pattern, this is not the most appropriate diagnosis for this patient because it does not address the root cause of the problem the patient is experiencing; it is an etiology of the main problem. The choice of Sexual Dysfunction would not be wrong; however, it is not the best choice for this patient because it does not address the primary cause (or etiology) of the patient's change in sexual intimacy. There are no data cues in the item to indicate that this patient is experiencing activity intolerance or fatigue.