Author Question: The nurse formulates the nursing diagnosis: Acute pain, related to tissue damage, secondary to ... (Read 78 times)

EY67 · **on:** Jul 23, 2018

The nurse formulates the nursing diagnosis: Acute pain, related to tissue damage, secondary to infarction, manifested by pallor, client report, and shallow, rapid breathing for a client experiencing an acute myocardial infarction.

Which collaborative action would be appropriate for this client?
1. Provide a calm, quiet atmosphere in the client's room.
2. Administer pain medication.
3. Educate the client and family regarding treatment and therapies.
4. Monitor for changes in the client's condition.

Question 2

A client who has just been diagnosed with pancreatic cancer is quite upset and verbal. The nurse has formulated the following diagnosis: Anxiety, related to unfamiliarity of disease process, manifested by restlessness and tachycardia.

What is the etiology of this diagnosis?
1. Unfamiliarity of disease process
2. Anxiety
3. Restlessness
4. Tachycardia

LVPMS · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 2
Rationale 1: This option is not collaborative but rather nurse mediated, which the nurse can implement independently.
Rationale 2: Collaboration occurs between the nurse, physician, and other health care professionals to treat the client's problem. In this case, the physician prescribes medications, and the nurse administers thema primarily dependent action that requires physician orders.
Rationale 3: This option is not collaborative but rather nurse mediated, which the nurse can implement independently.
Rationale 4: This option is not collaborative but rather nurse mediated, which the nurse can implement independently.

Answer to Question 2

Rationale 1: The etiology is the underlying cause and a contributing factor of the client's response. In this case, the uncertainty of the diagnosis, fear of the unknown, and response to the diagnosis cause the client to become anxious and upset.
Rationale 2: Anxiety is the NANDA labelthe problem identified.
Rationale 3: Restlessness is a defining characteristic that the client exhibits.
Rationale 4: Tachycardia is a defining characteristic that the client exhibits.