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A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?

Health promotion

Risk

Problem focused

Collaborative problem

Answer and Explanation

The Correct Answer is A

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.

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A. "Atelectasis affects only those with chronic conditions such as emphysema." B. "Hyperventilation will open up my alveoli, preventing atelectasis." C. "It is important to do breathing exercises every hour to prevent atelectasis." D. "If I develop atelectasis, I will need a chest tube to drain excess fluid."

Correct Answer is C

Explanation

A. Atelectasis can occur in anyone, not just those with chronic conditions; this statement is incorrect.

B. While hyperventilation may temporarily open alveoli, it is not a preventative measure for atelectasis.

C. Breathing exercises, such as incentive spirometry or deep breathing, are effective in preventing atelectasis by promoting lung expansion and alveolar ventilation.

D. A chest tube is typically used to remove air or fluid from the pleural space, not for the treatment of atelectasis, which is often managed with respiratory therapies.

A. Patient will increase activity level this shift. B. Patient will turn side to back to side with assistance every 2 hours. C. Patient will use the walker correctly to ambulate to the bathroom as needed. D. Patient will use a sliding board correctly to transfer to the bedside commode as needed.

Correct Answer is B

Explanation

A. Increasing activity level may be unrealistic for a patient on strict bed rest due to a pelvic fracture.

B. Repositioning every 2 hours is a realistic and achievable goal for a patient on bed rest to prevent complications such as pressure ulcers and maintain circulation.

C. Using a walker for ambulation may not be feasible immediately after a pelvic fracture.

D. Transferring with a sliding board may not be safe or appropriate in the early stages post-injury, especially if bed rest is required.

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Correct Answer is C

Explanation

Correct Answer is B

Explanation

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A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis?

Correct Answer is C

Explanation

A nurse is developing a care plan for a patient prescribed bed rest as a result of a pelvic fracture. Which goal statement is realistic for the nurse to assign to this patient?

Correct Answer is B

Explanation

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