Author Question: The nurse is caring for a patient admitted to the psychiatric unit as a result of an overdose of ... (Read 76 times)

berenicecastro · **on:** Jul 23, 2018

The nurse is caring for a patient admitted to the psychiatric unit as a result of an overdose of cocaine. Which nursing diagnosis indicates an understanding of a nursing diagnostic statement? (Select all that apply.)

a. Ineffective breathing pattern related to drug effect on the respiratory center
b. Risk for injury related to hallucinations
c. Insomnia
d. Chronic confusion related to excessive stimulation of nervous system as evidenced by impaired socialization
e. Personality conflict

Question 2

The nurse is developing a plan of care for a patient who has had a stroke. Assessment findings include weakness in right upper and lower extremities, numbness in face, slurred speech, and headache.

Which of the following would best represent the etiology of the patient's gait and balance problems?
a.
Lack of muscle motor movement
b.
Decreased sensation to touch
c.
Inability to speak clearly
d.
Pain in back of head

kaykay69 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: B, D
Each type of nursing diagnostic statement contains sections or parts. Actual nursing diagnostic statements are written with three parts: a diagnosis label, related factors, and defining characteristics. Risk nursing diagnoses have two segments: a diagnosis label and risk factors. Health-promotion nursing diagnoses are written with only two sections: the diagnosis label and defining characteristics.

Answer to Question 2

ANS: A
The related factor in an actual nursing diagnosis needs to address the underlying etiology of the patient's problem expressed by the nursing diagnostic label rather than listing data that are defining characteristics. The decreased sensation to touch, inability to speak clearly, and pain in the back of the head are only reiterations of the defining characteristics (numbness in face, slurred speech, and headache).