A nurse is providing care to a client that has been having pain without a clear etiology. Which nursing diagnosis should the nurse write as most appropriate for this client?

Acute pain manifested by client's report.

Acute pain related to psychosomatic condition.

Acute pain related to unknown etiology.

Acute pain related to unknown factors.

Answer and Explanation

The Correct Answer is C

A. Acute pain manifested by client's report: While this diagnosis reflects the client's report of pain, it does not address the underlying cause or etiology of the pain, which is important for forming an effective care plan.
B. Acute pain related to psychosomatic condition: This diagnosis implies a specific psychosomatic origin for the pain. Since the etiology is unknown, attributing it to a psychosomatic condition may not be accurate.
C. Acute pain related to unknown etiology: This diagnosis is the most appropriate because it acknowledges the presence of acute pain and explicitly notes that the cause is unknown, which aligns with the information provided.
D. Acute pain related to unknown factors: This diagnosis is similar to C, but "unknown factors" is less precise than "unknown etiology." The term "etiology" more accurately describes the underlying cause.

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Correct Answer is A

Explanation

A. Clean hands with soap and water after caring for the client: C. difficile spores are resistant to alcohol-based hand sanitizers. Therefore, it is essential to use soap and water to effectively remove the spores from hands.
B. Place the client in a room with negative pressure airflow: C. difficile is not an airborne infection, so negative pressure airflow is not required. This measure is typically used for infections such as tuberculosis.
C. Wash hands for 10 seconds after caring for the client: Handwashing with soap and water should be done for at least 20 seconds to effectively remove C. difficile spores.
D. Apply a mask on the client when they are outside their room: A mask is not necessary for clients with C. difficile, as the infection is not transmitted through respiratory droplets but rather through fecal-oral transmission.

A. Being a victim of a crime B. Motor vehicle accident C. Living in poverty D. Loss of a loved one

Correct Answer is C

Explanation

A. Being a victim of a crime: This is typically considered an acute stressor as it represents a single, intense event.
B. Motor vehicle accident: This also represents an acute stressor because it is a specific event with a defined beginning and end.
C. Living in poverty: This is an example of chronic stress as it involves ongoing, persistent stress over an extended period of time, affecting multiple aspects of life.
D. Loss of a loved one: While this is a significant stressor, it is often acute because it refers to a specific event. Chronic stress involves continuous or repeated stress over time.

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A nurse is providing care to a client that has been having pain without a clear etiology. Which nursing diagnosis should the nurse write as most appropriate for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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