If a post-operative client is complaining of pain at a level of 7 on a scale of 0-10, which type of nursing diagnosis would be appropriate?
Risk nursing diagnosis.
Actual nursing diagnosis.
Possible nursing diagnosis.
Wellness diagnosis.
The Correct Answer is B
Choice A rationale
A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual. It is supported by risk factors rather than current signs or symptoms. Since this client is currently experiencing a pain level of 7 out of 10, the problem is not a potential future occurrence but a current reality. Therefore, a risk diagnosis is insufficient because it does not address the physiological and psychological distress the client is actively feeling.
Choice B rationale
An actual nursing diagnosis represents a clinical judgment about a patient's response to a health condition that is currently present. It is validated by the presence of defining characteristics, such as the client's self-report of pain at a level of 7 on a 0 to 10 scale. Because the pain is a real-time problem requiring immediate nursing intervention and management, this category is the most appropriate to guide the care plan, aiming to reduce the intensity of the subjective discomfort.
Choice C rationale
A possible nursing diagnosis is used when the nurse suspects a problem may be present but requires more data to confirm it. In this scenario, there is no ambiguity; the client has clearly stated their pain level is high. Using a possible diagnosis would inappropriately delay necessary pharmacological or non-pharmacological interventions. Since the evidence of the pain is already documented through the client's verbalization, the diagnosis is confirmed and should be treated as a definitive clinical priority.
Choice D rationale
A wellness diagnosis, also known as a health promotion diagnosis, focuses on a client's transition from a specific level of wellness to a higher level of wellness. It is used when a client expresses a desire to enhance their health. A postoperative client experiencing significant pain is in a state of acute physiological stress, not a state of seeking optimal wellness. The priority in this case is the management of an acute symptom rather than long-term health optimization.
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Correct Answer is B
Explanation
Choice A rationale
Improvement would be characterized by a significant decrease in the client's temperature toward the normal range of 97 F to 99 F (36.1 C to 37.2 C). The initial temperature was 101.4 F (38.5 C) and the current reading is 101.1 F (38.4 C). A decrease of only 0.3 degrees remains well within the range of a high fever. This negligible change does not represent a resolution of the underlying inflammatory or infectious process.
Choice B rationale
The term no change is used when clinical parameters remain relatively stable or show no significant therapeutic progress. A temperature shift from 101.4 F (38.5 C) to 101.1 F (38.4 C) indicates that the client remains in a febrile state. Since both readings are significantly above the normal reference range and the change is minimal, the client's condition regarding thermoregulation is effectively the same. The underlying cause of the fever persists without significant alteration.
Choice C rationale
A complication usually refers to a new, worsening, or additional health problem that arises during the course of a condition. While the client has developed new gastrointestinal symptoms which are complications, the temperature itself has actually slightly decreased. Therefore, the temperature reading of 101.1 F is a continuation of the previous febrile state rather than a new complication in its own right, despite the fact that the overall clinical picture for the client is worsening.
Choice D rationale
A baseline finding represents the initial set of data collected against which future measurements are compared. The baseline temperature for this client was 101.4 F (38.5 C). While the current reading of 101.1 F (38.4 C) is similar to the baseline, the category of baseline finding is typically reserved for the very first measurement or a known healthy state. In a clinical evaluation of progress, this finding is best described as having no significant change from the initial assessment.
Correct Answer is B
Explanation
Choice A rationale
Respiratory alkalosis is characterized by a blood pH greater than 7.45 and a PaCO2 less than 35 mm Hg. This occurs when hyperventilation causes excessive elimination of carbon dioxide. The findings in this scenario, such as a pH less than 7.35 and a PaCO2 greater than 45 mm Hg, are the exact opposite of what is seen in alkalosis, indicating that the primary problem is an accumulation of acid rather than a deficit.
Choice B rationale
Respiratory acidosis occurs when the lungs cannot effectively remove the carbon dioxide produced by the body, leading to an increase in PaCO2 greater than 45 mm Hg and a decrease in pH less than 7.35. In pulmonary edema, fluid in the alveoli impairs gas exchange. This retention of CO2 leads to the formation of carbonic acid, resulting in the symptoms of headache, dizziness, mental cloudiness, and muscle twitching as seen here.
Choice C rationale
Metabolic acidosis involves a primary decrease in bicarbonate (HCO3) less than 22 mEq/L and a pH less than 7.35. While the pH in this scenario is low, the PaCO2 is elevated, which points toward a respiratory cause. In metabolic acidosis, the respiratory system usually attempts to compensate by increasing the rate and depth of breathing to blow off CO2, which would result in a low PaCO2, not an elevated one.
Choice D rationale
Metabolic alkalosis is defined by a pH greater than 7.45 and an HCO3 greater than 26 mEq/L. It can be caused by the loss of gastric acid through vomiting or the gain of bicarbonate. The client's findings of a low pH and high PaCO2 are inconsistent with an alkalotic state. In metabolic alkalosis, the body may attempt to compensate by hypoventilating to retain CO2, but the underlying pH would remain high.
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