Author Question: A client who is at 12 weeks' gestation is experiencing nausea, breast tenderness, and fatigue. She ... (Read 109 times)

TFauchery · **on:** Jun 25, 2018

A client who is at 12 weeks' gestation is experiencing nausea, breast tenderness, and fatigue. She tells the nurse her husband is upset with her constant complaints. Which is the priority nursing diagnosis based on this data?

A) Ineffective Breastfeeding
B) Dysfunctional Family Processes
C) Nausea
D) Fatigue

Question 2

A client with a long history of experiencing domestic violence tells the nurse, There is no way out for me; this situation will never change. What nursing diagnosis would be most appropriate?

A) Powerlessness
B) Risk for Other-Directed Violence
C) Ineffective Health Maintenance
D) Chronic Low Self-Esteem

shayla · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Answer: C

Of the three physiological complaints, the one that has the highest priority is nausea because it could directly impact the developing fetus. Breast tenderness does not mean that the client will experience ineffective breastfeeding. Fatigue is a common symptom of pregnancy and would not negatively impact the developing fetus. The husband being upset with the client's complaints does not necessarily mean that she and her husband have dysfunctional family processes.

Answer to Question 2

Answer: A

Powerlessness is indicated when the client feels an inability to change the pattern or to leave the situation. The victim may experience health maintenance problems as a result of experiencing domestic violence; however, this is not the primary diagnosis. Some victims will experience self-esteem issues, which are secondary to their feeling of having little or no control over their lives. The client is not at high risk for other-directed violence but is rather at high risk to experience it.