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 D
Explanation
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.
Correct Answer is A
Explanation
A. Hyperkalemia can lead to dangerous cardiac arrhythmias and other heart-related complications due to its effect on the electrical conduction system of the heart, making cardiac assessment the priority.
B. While neurological assessment is important in various conditions, it is secondary to assessing cardiac status in hyperkalemia.
C. Gastrointestinal symptoms can occur with hyperkalemia, but they do not pose an immediate life-threatening risk like cardiac issues do.
D. Respiratory assessment is essential in many contexts, but the immediate threat of hyperkalemia lies in its impact on heart function, making cardiac assessment the most critical.