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. Discontinuing pain medication may not be appropriate, as it can lead to inadequate pain management for the patient. Pain management is crucial for terminally ill patients.
B. While abdominal massage may help relieve mild constipation, it is not a reliable primary intervention for more severe constipation caused by medication.
C. Laxatives are commonly prescribed for constipation related to pain medication and are an effective method to promote bowel movements, making this the best choice.
D. Administering enemas twice daily can be excessive and may cause discomfort or lead to dependency, making this option less favorable than using laxatives.
Correct Answer is C
Explanation
A. While metabolic acidosis is a potential concern for some diabetic conditions, avoiding acidic foods is not a common dietary guideline for managing diabetes.
B. Including dairy can contribute to calcium intake but does not directly impact diabetes management.
C. Staying hydrated is essential for overall health and helps regulate blood sugar levels, making it an appropriate dietary recommendation for this patient.
D. Since the patient does not require insulin, strict carbohydrate reduction may not be necessary, making this option less relevant.