A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
Risk for infection related to chest x-ray procedure
Impaired gas exchange related to alveolar-capillary membrane changes
Risk for deficient fluid volume related to dehydration
Ineffective breathing pattern related to pneumonia
The Correct Answer is B
A. "Risk for infection related to chest x-ray procedure" is not an appropriate diagnosis because a chest x-ray is a diagnostic tool, and pneumonia itself is the concern for infection.
B. "Impaired gas exchange related to alveolar-capillary membrane changes" is correct as pneumonia causes inflammation and consolidation in the lungs, which directly impacts gas exchange.
C. "Risk for deficient fluid volume related to dehydration" does not apply specifically to pneumonia unless the patient presents signs of dehydration, which is not indicated in the scenario.
D. "Ineffective breathing pattern related to pneumonia" could also be a valid diagnosis, but the primary concern given the information provided is gas exchange impairment.
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Correct Answer is C
Explanation
A. Cultural values regarding cleanliness vary, so it is inaccurate to assume uniform standards.
B. Judging the patient as placing "little importance" on hygiene due to appearance can lead to biases and does not consider the patient’s routine.
C. Diabetes may necessitate changes in hygiene practices, especially regarding foot care, to prevent complications. Education on optimal hygiene practices is essential for health management in diabetic patients.
D. While personal preferences influence hygiene, they can be adapted with appropriate education and guidance when necessary for health reasons.
Correct Answer is D
Explanation
A. Chest physiotherapy is used to mobilize secretions and improve lung function, not specifically for increasing stroke volume or preload.
B. Diuretics would decrease preload by removing excess fluid, which is counterproductive in a patient with inadequate stroke volume related to decreased preload.
C. Vasodilators can further decrease preload and are not appropriate in this scenario where preload needs to be increased.
D. Intravenous (IV) fluids are administered to increase preload and improve stroke volume by enhancing the circulating blood volume.