Author Question: A client with a new colostomy often becomes short and sarcastic when nurses attempt to teach him ... (Read 37 times)

nevelica · **on:** Jul 23, 2018

A client with a new colostomy often becomes short and sarcastic when nurses attempt to teach him about the management of his new appliance. The nurse has consequently documented Noncompliance related hostility on the client's chart.

What mistake has the nurse made when choosing and documenting this nursing diagnosis?

A) Presuming to know the factors contributing to the problem
B) Identifying a problem that cannot be changed
C) Identifying a problem without corroborating evidence in the statement
D) Neglecting to identify potential complications related to the problem

Question 2

In planning the care for a client who has pneumonia, the nurse collects data and develops nursing diagnoses. Which of the following is an example of a properly developed nursing diagnosis?

A) Ineffective airway clearance as evidenced by inability to clear secretions
B) Ineffective health maintenance as evidenced by unhealthy habits
C) Ineffective breathing pattern related to pneumonia
D) Ineffective therapeutic regimen management due to smoking

momtoalll · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Ans: A

Multiple factors may underlie the client's response to education in a complex and emotionally charged situation, such as receiving a new ostomy. As a result, it is likely presumptuous to ascribe the client's response to hostility. The problem is likely modifiable with a correct approach; the evidence underlying a nursing diagnosis is not normally explicit in the statement itself. The existence of potential complications is not central to the psychosocial nature of this client's situation.

Answer to Question 2

Ans: A

The appropriately written nursing diagnosis is ineffective airway clearance related to inability to clear secretions. Ineffective health maintenance related to unhealthy habits is incorrect because it shows value judgments by the nurse. Ineffective breathing pattern related to pneumonia is incorrectly written because it includes a medical diagnosis. Ineffective therapeutic regimen management due to smoking is incorrect because the clause due to implies a direct cause-and-effect relationship.