One of the interventions for a client with a nursing diagnosis of ...

[penza]

One of the interventions for a client with a nursing diagnosis of Impaired swallowing is to position the client upright in a chair (60 to 90 degrees) during feeding times. What should the nurse identify as the modifier in this intervention?
 
  1. 60 to 90 degrees during feeding times
  2. Position in chair
  3. Upright in a chair
  4. Impaired swallowing

Question 2

A nurse is caring for a client who has a diagnosis of Impaired skin integrity, related to immobility, secondary to neurologic dysfunction. Which should the nurse identify as an observation intervention?
 
  1. Turn and reposition client every 2 hours.
  2. Cushion bony prominences with soft foam while in bed.
  3. Provide ongoing assessment for skin breakdown every shift.
  4. Apply lotion to dry skin twice daily.

[tdewitt]

Answer to Question 1

Correct Answer: 1
Rationale 1: Conditions or modifiers may be added to the verb to explain the circumstances under which the behavior is to be performed. They explain what, where, when, or how. In this case, defining upright as 60 to 90 degrees and during feeding times gives when this should be done.
Rationale 2: The word position is not descriptive enough for modifiers.
Rationale 3: The word upright is not descriptive enough for modifiers.
Rationale 4: Impaired swallowing is the NANDA label.

Answer to Question 2

Correct Answer: 3
Rationale 1: Prevention interventions prescribe the care needed to avoid complications or reduce risk factors. Turning and repositioning would help prevent any further skin breakdown.
Rationale 2: Prevention interventions prescribe the care needed to avoid complications or reduce risk factors. Cushioning bony prominences would help prevent any further skin breakdown.
Rationale 3: Observations include assessments made to determine whether a complication is developing as well as observations of the client's responses to nursing and other therapies. Assessment for skin breakdown would fall under this category.
Rationale 4: Application of lotion or other treatments to areas of skin impairment would be considered a treatment intervention.

[penza]

Excellent

[kusterl]

TYSM