Author Question: The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation ... (Read 116 times)

LaDunn · **on:** Jul 22, 2018

The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, reports of shortness of breath when getting out of bed, and a productive cough.

Which elements will the nurse identify as defining characteristics for the diagnostic label of Activity intolerance?
a. Decreased oral intake and decreased oxygen saturation when ambulating
b. Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed
c. Reports of shortness of breath when getting out of bed and a productive cough
d. Productive cough and decreased oral intake

Question 2

A nurse adds the following diagnosis to a patient's care plan:

Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic?
a. Decreased gastrointestinal motility
b. Pain medication
c. Abdominal distention
d. Constipation

gstein359 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: B
There are defining characteristics (observable assessment cues such as patient behavior, physical signs) that support each problem-focused diagnostic judgment. The signs and symptoms, or defining characteristics, for the diagnosis Activity intolerance include decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed. The key to supporting the diagnosis of Activity intolerance is that only these two characteristics involve how the patient tolerates activity. Decreased oral intake and productive cough do not define activity intolerance.

Answer to Question 2

ANS: C
Abdominal distention, no reported bowel movement, and abdominal pain are the defining characteristics. Decreased gastrointestinal motility secondary to pain medication is an etiology or related to factor. Constipation (problem or NANDA-1 diagnosis) is the identified problem derived from the defining characteristics.