The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?
Nursing diagnosis
Collaborative problem
Defining characteristic
Etiology
The Correct Answer is D
A. The nursing diagnosis "Impaired physical mobility" is appropriate and does not need revision.
B. There is no collaborative problem mentioned in the statement that requires revision.
C. The defining characteristic "patient's inability to ambulate" accurately reflects the patient's current condition and does not need changes.
D. The etiology "related to tibial fracture" should be revised to reflect a more precise causal factor that can be addressed by nursing interventions. A more appropriate etiology could specify the limitation in mobility rather than just stating the fracture.
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Correct Answer is C
Explanation
A. Elevated blood pressure may occur with various conditions but is not a specific late sign of hypoxia.
B. An increased pulse rate can be an early compensatory response to hypoxia rather than a late sign.
C. Cyanosis, which is a bluish discoloration of the skin and mucous membranes, is a classic late sign of hypoxia, indicating severe oxygen deprivation.
D. Restlessness may indicate early signs of hypoxia or anxiety rather than a late sign and can occur before cyanosis develops.
Correct Answer is A
Explanation
A. Compassion fatigue is characterized by burnout and secondary traumatic stress, which result from prolonged exposure to caring for patients in distress and trauma, leading to emotional exhaustion.
B. Lateral violence and intrapersonal conflict involve hostile behavior and internal personal issues, which do not define compassion fatigue.
C. While physical and mental exhaustion can occur with compassion fatigue, they are not the defining aspects without the context of prolonged trauma exposure.
D. Short-term grief and a single stressor do not capture the chronic nature of compassion fatigue, which builds over repeated exposure to others' suffering.