Which of the following is an example of a nursing diagnosis?
Skin breakdown
Elevated blood pressure
Anxiety
Ineffective breathing pattern
The Correct Answer is D
A. Skin breakdown: This is a medical problem or symptom, but it is not a structured nursing diagnosis.
B. Elevated blood pressure: This is a clinical finding rather than a nursing diagnosis.
C. Anxiety: While anxiety is a medical condition, a complete nursing diagnosis should describe the specific effects on the patient, such as "Anxiety related to hospitalization as evidenced by restlessness and increased heart rate."
D. Ineffective breathing pattern: This is a standardized nursing diagnosis as defined by NANDA (North American Nursing Diagnosis Association). It refers to altered respiratory function that nurses can assess and manage.
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Related Questions
Correct Answer is A
Explanation
A. Discharge teaching: Phase III of post-anesthesia care focuses on preparing the patient for discharge, including teaching about post-operative care, medication instructions, and follow-up care.
B. Recovery from anesthesia: This occurs in Phase I, where patients are closely monitored as they emerge from anesthesia and regain protective reflexes.
C. Urinary catheterization if no voiding: This may be considered in Phase II, especially if urinary retention is present, but is not a defining activity of Phase III.
D. Vital signs every 15 to 30 minutes: Frequent monitoring of vital signs is a key part of Phase I, when patients are at the highest risk for complications.
Correct Answer is B
Explanation
A. Nonrebreather mask. A nonrebreather mask delivers high concentrations of oxygen but requires a tight seal around the face, which is not suitable for patients with facial trauma.
B. Face tent. A face tent is the best option for a patient with facial trauma as it provides high-flow oxygen without requiring direct contact with the face, preventing pressure on injured areas.
C. Nasal cannula. A nasal cannula provides low-flow oxygen and may be ineffective for a patient requiring high-flow therapy.
D. Venturi mask. A Venturi mask delivers precise oxygen concentrations but still requires a snug fit on the face, which may not be comfortable or feasible for a patient with facial trauma.
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