The most appropriate nursing diagnosis for a patient with ...

[ap345]

The most appropriate nursing diagnosis for a patient with postpartum deep vein thrombosis is:
 
  1. Fluid Volume excess related to tissue edema.
  2. Sleep Pattern Disturbance related to tissue hypoxia.
  3. Risk for Infection related to obstructed venous return.
  4. Altered Tissue Perfusion related to obstructed venous return.

Question 2

The patient at 34 weeks' gestation has been stabbed in the low abdomen by her boyfriend. She is brought to the emergency department for treatment.
 
  Which statements indicate that the patient understands the treatment being administered? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The baby needs to be monitored to check the heart rate.
  2. My bowel has probably been lacerated by the knife.
  3. I might need an ultrasound to look at the baby.
  4. The catheter in my bladder will prevent urinary complications.
  5. The IV in my arm will replace the amniotic fluid if it is leaking.

[ebe]

Answer to Question 1

4
Rationale 1: This diagnosis does not identify the underlying cause.
Rationale 2: This diagnosis does not identify the underlying cause.
Rationale 3: This might be a possible diagnosis if complications of infection are present.
Rationale 4: This diagnosis identifies the underlying cause.

Answer to Question 2

1,3
Rationale 1: Penetrating trauma to the abdomen during advanced pregnancy often results in ruptured membranes, with external leaking of fluid. The baby will be evaluated with electronic fetal monitoring and ultrasound examination to determine hemodynamic stability and look for injuries.
Rationale 2: The pregnancy usually sustains the majority of the damage, sparing the bowel from injury.
Rationale 3: The baby will be evaluated with electronic fetal monitoring and ultrasound examination to determine hemodynamic stability and look for injuries.
Rationale 4: The Foley catheter is placed to assess for hematuria.
Rationale 5: The IV will replace intravascular volume, not amniotic fluid.

[ap345]

TYSM

[Jossy]

Gracias!