A nurse is performing an assessment on a client who has been admitted for hip replacement surgery the
next day. The client is tearful and appears very anxious. The nurse is considering "anxiety" as a nursing
diagnosis
...
A nurse is performing an assessment on a client who has been admitted for hip replacement surgery the
next day. The client is tearful and appears very anxious. The nurse is considering "anxiety" as a nursing
diagnosis but does not have enough information. Which would be the appropriate action?
1.
Assume the anxiety is related to surgery.
2.
Inform the physician that the client is anxious.
3.
Ask the client to try to remain calm during the assessment.
4.
Ask the client if there is anything in particular he or she is anxious about. - ✔✔4) Ask the client if there is
anything in particular he or she is anxious about.
Rationale:
Asking open-ended questions can help identify specific reasons for anxiety, and the nurse can direct
teaching and interventions toward alleviating anxiety based on the etiology.
Why is the diagnosis step critical to the nursing process?
1.
It connects the assessment with planning, interventions, and follow-up evaluation.2.
Without a complete nursing diagnosis, insurance will not compensate the hospital.
3.
It provides the physician with necessary information to make a medical diagnosis.
4.
Nursing diagnoses are needed to support any therapeutic treatments and diagnostic testing. - ✔✔1.
It connects the assessment with planning, interventions, and follow-up evaluation.
Rationale:
The nursing diagnosis step is critical because it links the assessment step, which precedes it, to all the
steps that follow it. However, assessment data must be complete and accurate in order to make an
accurate nursing diagnosis.
Which is the best explanation of the difference between a medical diagnosis and a nursing diagnosis?
1.
A medical diagnosis defines an illness or disease with a certain pathology, while a nursing diagnosis is
geared toward the client's health status and how a nurse can help independently.
2.
A medical diagnosis is made by a physician, and a nursing diagnosis is created by a nurse.
3.A medical diagnosis involves interventions and medical treatment, and a nursing diagnosis involves
client comfort and activities of daily living.
4.
A medical diagnosis determines the nursing diagnosis, while the nursing diagnosis has no bearing on the
medical diagnosis. - ✔✔1.
A medical diagnosis defines an illness or disease with a certain pathology, while a nursing diagnosis is
geared toward the client's health status and how a nurse can help independently.
Rationale:
A medical diagnosis describes a disease, illness, or injury, and the purpose is to find pathology. A nursing
diagnosis is a statement of client health status that nurses can identify, prevent, or treat independently.
A nurse has created a plan of care that involves assisting a client with ambulation. She attempts to get
the client out of bed, but the client is obese and unable to move without pain. What action should the
nurse take?
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