Author Question: The nurse is formulating a nursing diagnosis for a client with a long, extensive history of ... (Read 34 times)

awywial · **on:** Jul 23, 2018

The nurse is formulating a nursing diagnosis for a client with a long, extensive history of psychiatric problems, beginning in childhood, who is being placed in a long-term, structured institutional environment.

Which diagnosis indicates the client's problem is adequately described?
1. Chronic low self-esteem, related to factors too numerous to mention
2. Risk for self-harm, related to many psychiatric problems
3. Impaired social interaction, due to long history of institutionalizatio n
4. Alteration in thought processes, related to complex factors

Question 2

A client is diagnosed with pneumonia and has been hospitalized for several days. Which nursing diagnosis should the nurse identify as a priority for this client?

1. Altered oral mucous membranes, related to dry mouth
2. Activity intolerance, related to oxygen supply imbalance
3. Knowledge deficit, related to medication regimen
4. Ineffective airway clearance, related to increased secretions

nicoleclaire22 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 4
Rationale 1: This option poorly describes the causing factors.
Rationale 2: This option poorly describes the causing factors.
Rationale 3: This option limits the description of causing factors.
Rationale 4: The phrase complex factors may be used when there are too many etiologic factors or when they are too complex to state in a brief phrase. The actual cause of this client's altered thought process may be due to psychiatric diagnoses, medication tolerances and noncompliance, history of institutionalizatio n, and life history of mental disease. This is a variation of the basic two-part statement, but is acceptable to use.

Answer to Question 2

Correct Answer: 4
Rationale: Prioritizing care must begin with the basic needs. This option is appropriate but does not match the primary need.