A nurse is providing care to a client that has been having pain without a clear etiology. Which nursing diagnosis should the nurse write as most appropriate for this client?
Acute pain manifested by client's report.
Acute pain related to psychosomatic condition.
Acute pain related to unknown etiology.
Acute pain related to unknown factors.
The Correct Answer is C
A. Acute pain manifested by client's report: While this diagnosis reflects the client's report of pain, it does not address the underlying cause or etiology of the pain, which is important for forming an effective care plan.
B. Acute pain related to psychosomatic condition: This diagnosis implies a specific psychosomatic origin for the pain. Since the etiology is unknown, attributing it to a psychosomatic condition may not be accurate.
C. Acute pain related to unknown etiology: This diagnosis is the most appropriate because it acknowledges the presence of acute pain and explicitly notes that the cause is unknown, which aligns with the information provided.
D. Acute pain related to unknown factors: This diagnosis is similar to C, but "unknown factors" is less precise than "unknown etiology." The term "etiology" more accurately describes the underlying cause.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Droplet: Incorrect. Droplet precautions are used for infections spread through respiratory droplets, such as influenza or meningitis, not for immunocompromised clients undergoing stem-cell transplants.
B. Protective: Correct. Protective precautions, also known as neutropenic precautions or reverse isolation, are necessary for clients who are immunocompromised, such as those who have had a stem-cell transplant. These precautions include using barrier protection to prevent infection due to the client's weakened immune system.
C. Contact: Incorrect. Contact precautions are used for infections spread by direct or indirect contact with contaminated surfaces or items, such as Clostridium difficile, not for immunocompromised patients.
D. Airborne: Incorrect. Airborne precautions are used for infections that spread through the air over long distances, such as tuberculosis or measles, and are not specifically needed for clients with compromised immunity post-transplant.
Correct Answer is C
Explanation
A. Question-and-answer: This strategy involves the nurse asking questions to assess the client's understanding and provide information, but it does not involve the client performing the skill.
B. Role-play: Role-play involves the client acting out scenarios to practice skills, but this is not the method being described where the client is simply asked to perform a skill.
C. Return demonstration: This strategy involves the client performing a skill or procedure after being shown how to do it, allowing the nurse to assess the client's competence in the skill. This is the method being described in the scenario.
D. Discussion: Discussion involves talking through concepts or information but does not include the client actively performing a skill.
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