The following NANDA-I nursing diagnostic stem was developed for a ...

[penguins]

The following NANDA-I nursing diagnostic stem was developed for a client on an inpatient unit: Risk for injury. What assessment data most likely led to the development of this problem statement?
 
  1. The client is receiving ECT and is diagnosed with Parkinsonism.
  2. The client has a history of four suicide attempts in adolescence.
  3. The client expresses hopelessness and helplessness and isolates self.
  4. The client has disorganized thought processes and delusional thinking.

Question 2

A newly married woman comes to a gynecology clinic reporting anorexia, insomnia, and extreme pain during intercourse that has affected her intimate relationship. What initial intervention should the nurse expect a physician to implement?
 
  1. A thorough physical, including gynecological examination
  2. Referral to a sex therapist
  3. Assessment of sexual history and previous satisfaction with sexual relationships
  4. Referral to the recreational therapist for relaxation therapy

[milbourne11]

Answer to Question 1

1
Rationale: The nurse should identify that a client receiving ECT and who is diagnosed with Parkinsonism is at risk for injury. History of suicide, hopelessness, and disorganized thoughts would not lead the nurse to formulate a nursing diagnostic stem of Risk for injury.

Answer to Question 2

1
Rationale: The nurse should expect the physician to implement a thorough physical, including a gynecological examination to assess for any physiological causes of the client's symptoms. If no pathology exists the client may be diagnosed with genito-pelvic pain/penetration disorder. In this disorder, the individual experiences considerable difficulty with vaginal intercourse and attempts at penetration. Pain is felt in the vagina, around the vaginal entrance and clitoris, or deep in the pelvis. There is fear and anxiety associated with anticipation of pain or vaginal penetration. A tensing and tightening of the pelvic floor muscles occurs during attempted vaginal penetration.

[penguins]

TY

[milbourne11]

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