A nurse assesses a patient who reports chest pain radiating down their arm. The nurse notes the patient is sweating and pale, BP 90/50 mmHg, pulse 120bpm, irregular. When developing the plan of care, what type of nursing diagnosis should the nurse use?

Risk

Actual

Syndrome

Wellness

Answer and Explanation

The Correct Answer is B

A. A risk diagnosis applies when a problem has not yet occurred but is likely. This patient is already experiencing chest pain and hemodynamic instability, requiring an actual diagnosis.

B. The patient has current symptoms of chest pain, sweating, pallor, hypotension, and an irregular pulse, indicating a medical condition (possibly myocardial infarction). This justifies an actual diagnosis.

C. Syndrome diagnoses involve a cluster of related diagnoses, such as frail elderly syndrome. This patient’s case does not meet that definition.

D. Wellness diagnoses focus on improving health, not addressing an active medical crisis.

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Correct Answer is D

Explanation

A. A patient who is scheduled for a routine follow-up visit for hypertension management. This is incorrect because this patient is stable and does not require immediate assessment. Routine follow-ups do not take priority over acute conditions.

B. A patient who is receiving antibiotics for a urinary tract infection and is requesting assistance with personal hygiene. This is incorrect because while personal hygiene is important, it is not urgent or life-threatening.

C. A patient who is recovering from an appendectomy and is asking about discharge instructions. This is incorrect because discharge teaching is important but can be scheduled later in the shift when more urgent needs have been addressed.

D. A patient who is complaining of sudden onset chest pain and shortness of breath. This is correct because sudden onset chest pain and shortness of breath can indicate a life-threatening condition such as myocardial infarction or pulmonary embolism. The nurse must immediately assess this patient to determine the cause and initiate emergency interventions if necessary.

A. Review the patient's medication history for any potential drug interactions. B. Educate the patient about the potential side effects of the new medication. C. Document the patient's baseline blood pressure before starting the medication. D. Assess the patient's blood pressure to determine if the medication is effective.

Correct Answer is D

Explanation

A. Reviewing medication history is important before starting a medication, not during the evaluation phase.

B. While education is important, the priority in the evaluation phase is determining whether the medication is working.

C. Baseline data is collected before treatment begins. The evaluation phase focuses on assessing the effectiveness of treatment.

D. The evaluation phase of the nursing process focuses on determining if interventions (such as medications) have achieved the desired outcomes.

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A nurse assesses a patient who reports chest pain radiating down their arm. The nurse notes the patient is sweating and pale, BP 90/50 mmHg, pulse 120bpm, irregular. When developing the plan of care, what type of nursing diagnosis should the nurse use?

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