Nursing students are analyzing the following nursing diagnostic ...

[V@ndy87]

Nursing students are analyzing the following nursing diagnostic statement during a study group session.
 
  Acute pain related to pressure on lumbar spinal nerves as evidenced by a pain level of 9, patient verbalizations of pain, and grimacing when walking. The students would be correct if they stated that the etiology of the patient's problem is:
  a.
  patient verbalizations of pain.
  b.
  acute pain.
  c.
  pressure on lumbar spinal nerves.
  d.
  grimacing when walking.

Question 2

The nurse is writing the care plan for a patient admitted to the hospital for complications associated with muscular dystrophy. Which nursing diagnoses written on the care plan indicate a need for further instruction in constructing the diagnostic stateme
 
  a. Constipation related to immobility as manifested by lower extremity weakness.
  b. Activity intolerance related to weakness as evidenced by verbal report of fatigue.
  c. Feeding self-care deficit related to fatigue as manifested by inability to swallow food.
  d. Ineffective airway clearance related to muscle weakness.

[quynhmickitran]

Answer to Question 1

ANS: C
According to the NANDA-I guidelines, the second part of the nursing diagnosis consists of related factors (for actual nursing diagnoses) and risk factors (for risk nursing diagnoses). Related factors are the underlying cause or etiology of a patient's problem. Risk factors are environmental, physical, psychological, or situational concerns that increase a patient's vulnerability to a potential problem or concern. In this case, the acute pain is being caused by pressure on the lumbar spinal nerves.

Answer to Question 2

ANS: D
Each type of nursing diagnostic statement contains sections or parts. Actual nursing diagnostic statements are written with three parts: a diagnosis label, related factors, and defining characteristics. Risk nursing diagnoses have two segments: a diagnosis label and risk factors. Health-promotion nursing diagnoses are written with only two sections: the diagnosis label and defining characteristics. The ineffective airway clearance label is missing the defining characteristics.

[V@ndy87]

Thank you!

[quynhmickitran]

Always glad to help...