While completing an admission database, the nurse is interviewing ...

[bucstennis@aim.com]

While completing an admission database, the nurse is interviewing a patient who states that he is allergic to latex. The most appropriate nursing action is to first
 
  a. Leave the room and place the patient in isolation.
  b. Ask the patient to describe the type of reaction.
  c. Proceed to the termination phase of the interview.
  d. Document the latex allergy on the medication administration record.

Question 2

The patient weighs 450 lbs (204.5 kg) and complains of shortness of breath with any exertion. His health care provider has recommended that he begin an exercise program.
 
  He states that he can hardly get out of bed and just cannot do anything around the house. To focus on the cause of the patient's complaints, the nurse devises which of the following nursing diagnoses? a. Activity intolerance related to excessive weight
  b. Activity intolerance related to bed rest
  c. Impaired gas exchange related to shortness of breath
  d. Imbalanced nutrition: less than body requirements

[iceage]

Answer to Question 1

B
The nurse should further assess and ask the patient to describe the type of reaction. The patient will not need to be placed in isolation; before terminating the interview or documenting the allergy, health care personnel need to be aware of what type of response the patient suffered.

Answer to Question 2

A
The diagnostic label directs nursing interventions. This requires the correct selection of related factors. For example, Activity intolerance related to excess weight gain requires very different interventions than if the related factor is prolonged bed rest. In this case, the intolerance is related to the patient's excessive weight. He is not on bed rest, although he claims that it is difficult for him to get out of bed. Shortness of breath is a symptom, not a cause, of Impaired gas exchange, making this nursing diagnosis ineffective. The patient certainly has an imbalance of nutrition, but it is more than body requirements.