Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved?
Acute pain
Sore throat
Sleep apnea
Heart failure
The Correct Answer is A
A. "Acute pain" is a NANDA-I approved nursing diagnosis that identifies a specific condition that nursing interventions can address.
B. "Sore throat" is a symptom rather than a nursing diagnosis and does not appear in NANDA-I.
C. "Sleep apnea" is classified as a medical diagnosis and not as a nursing diagnosis within NANDA-I.
D. "Heart failure" is also a medical diagnosis and not an approved nursing diagnosis, as it describes a condition rather than the patient's response or nursing concerns.
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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 C
Explanation
A. Assertiveness training may benefit family communication but is not specifically effective in managing homework stress.
B. Routine preventative health visits are important for overall health but do not directly address homework-related stress.
C. Teaching time-management skills helps children with ADHD better organize their tasks and allocate appropriate time for homework, thus reducing stress and improving academic performance.
D. Speech articulation skills focus on communication and language development, which are not directly related to managing homework stress for children with ADHD.