A patient is admitted with acute respiratory distress and anxiety. Based on NANDA guidelines, which nursing diagnosis is most appropriate to address both conditions?
Ineffective airway clearance
Risk for infection
Anxiety related to hospitalization
Impaired gas exchange related to anxiety and respiratory distress
The Correct Answer is D
A. Ineffective airway clearance: This diagnosis focuses on obstruction of the airway by secretions or mechanical blockage. While relevant to some respiratory conditions, it does not directly address gas exchange impairment or the client’s anxiety.
B. Risk for infection: This diagnosis addresses potential for infection rather than current acute symptoms. It is preventive in nature and does not target immediate respiratory compromise or emotional distress.
C. Anxiety related to hospitalization: This diagnosis addresses only the psychological component. While the patient is anxious, this alone does not encompass the physiological issue of impaired oxygenation.
D. Impaired gas exchange related to anxiety and respiratory distress: This diagnosis integrates both physiologic and psychological factors affecting oxygenation. Anxiety can exacerbate respiratory distress, and this NANDA diagnosis allows for interventions targeting both improved oxygenation and anxiety reduction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Focusing solely on physical symptoms and ignoring emotional needs: Palliative care addresses the whole person, including emotional, psychological, spiritual, and social needs. Ignoring emotional aspects does not align with palliative care principles.
B. Discontinuing all medications: Stopping medications without considering symptom management or quality of life can cause unnecessary suffering. Palliative care focuses on comfort, not indiscriminate discontinuation of treatments.
C. Encouraging the client to undergo aggressive curative treatments: Palliative care emphasizes quality of life and symptom relief rather than pursuing aggressive interventions when they may not provide meaningful benefit.
D. Managing the client's dyspnea and pain effectively: Symptom management, such as controlling dyspnea and pain, is central to palliative care. This approach prioritizes comfort, dignity, and quality of life for clients with advanced illness.
Correct Answer is A
Explanation
A. Document the findings and notify the healthcare provider: Purulent drainage is a clear sign of infection and may indicate a need for prompt medical intervention, such as antibiotics. The nurse’s first action should be to notify the provider and document the findings to ensure timely, appropriate care.
B. Increase the frequency of dressing changes: While changing the dressing may help manage drainage, it does not address the underlying infection or the need for provider-directed treatment. Immediate notification is more critical.
C. Clean the wound with sterile saline and apply a new dressing: Maintaining wound hygiene is important, but it should follow assessment and provider notification. Acting first without notifying the provider may delay necessary treatment.
D. Reassess the wound for additional signs of infection later in the shift: Delaying assessment could allow the infection to worsen. Immediate documentation and communication with the provider are essential to prevent complications.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.