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 A
Explanation
A. "Readiness for enhanced urinary elimination" is classified as a health promotion diagnosis, indicating the patient’s desire to improve their health condition and adopt new health behaviors.
B. A risk diagnosis is used when there is a potential for problems to occur, not applicable in this scenario as the patient is actively seeking improvement.
C. A problem-focused diagnosis describes an existing problem that requires intervention; this situation reflects readiness for improvement, not an existing issue.
D. A collaborative problem involves potential complications that require both nursing and medical management; this case focuses on the patient's willingness to learn a self-management skill rather than managing a specific medical problem.
Correct Answer is C
Explanation
A. Certification relates to additional qualifications and does not directly involve independent nursing actions in patient care.
B. Licensure is the legal permission to practice nursing but does not describe decision-making and action in patient care.
C. Autonomy is demonstrated when the nurse independently assesses the patient’s fluid status and takes action to promote health by encouraging fluid intake. This reflects the nurse’s ability to make decisions and act based on professional judgment.
D. Accountability refers to being responsible for one's actions but does not specifically cover the independent decision-making shown here.