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.
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Related Questions
Correct Answer is A
Explanation
A. Orthostatic hypotension increases a client's risk of a fall: Correct. Orthostatic hypotension can lead to dizziness or lightheadedness when standing, increasing the risk of falls.
B. Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg: This is not specific enough. Orthostatic hypotension is typically defined by a decrease in systolic blood pressure of 20 mm Hg or more when standing.
C. Orthostatic hypotension increases a client's risk of a pulmonary emboli: This is not directly related. Orthostatic hypotension mainly affects balance and fall risk, not the risk of pulmonary emboli.
D. Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg: This is incorrect. Orthostatic hypotension is more commonly assessed by a significant drop in systolic blood pressure rather than diastolic pressure.
Correct Answer is ["B","C","D"]
Explanation
A. Remove the dentures from the body: Dentures should typically be left in place unless otherwise directed, as removing them can alter the appearance of the deceased and may be distressing for the family.
B. Dim the lights in the room: Dimming the lights can create a more respectful and soothing environment for the family during their time of mourning.
C. Remove all equipment from the bedside: Removing equipment ensures a clear and respectful presentation of the body, allowing the family to view their loved one without distractions.
D. Apply fresh linens and place a clean gown on the body: This action helps present the body in a respectful manner, making it more presentable for the family.
E. Make sure the body is lying completely flat: The body should be positioned appropriately based on the clinical setting and family preferences, but the focus should be on creating a respectful and dignified presentation rather than strictly ensuring the body is completely flat.
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