What is an appropriate nursing diagnosis for Mr. Carter?
Risk for infection
Ineffective health maintenance related to knowledge deficit
Acute pain
Risk for fluid volume deficit
Increase intake of processed foods
The Correct Answer is B
Choice A reason: Risk for infection is not specific to Mr. Carter’s context unless evidence of wounds or immunosuppression exists. Hypertension management focuses on lifestyle and medication adherence, not infection, making this an incorrect nursing diagnosis compared to addressing knowledge deficits in health maintenance.
Choice B reason: Ineffective health maintenance related to knowledge deficit is appropriate for Mr. Carter, likely a hypertensive patient needing education on lifestyle changes and medication adherence. This diagnosis addresses the need for teaching to improve self-management, making it the most relevant for optimizing his hypertension control and health outcomes.
Choice C reason: Acute pain is not typically associated with hypertension unless complications like angina occur. Mr. Carter’s primary issue is managing hypertension, not pain, making this an incorrect diagnosis, as knowledge deficits in health maintenance are more relevant to his condition and care needs.
Choice D reason: Risk for fluid volume deficit is less relevant for hypertension, which often involves fluid overload. Diuretics may cause depletion, but the primary issue is health maintenance through education, making this an incorrect diagnosis compared to addressing Mr. Carter’s need for hypertension management knowledge.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Pulmonary embolism obstructs pulmonary arteries, impairing gas exchange and causing hypoxemia. Oxygen therapy is the priority to correct hypoxia, stabilize respiratory status, and prevent tissue damage. This addresses the immediate life-threatening complication, ensuring adequate oxygen delivery before other interventions like fluids or monitoring are implemented.
Choice B reason: IV lactated Ringer’s supports volume status but is not the priority in pulmonary embolism, where hypoxemia is the primary threat. Oxygen therapy directly addresses impaired gas exchange, while fluids are secondary to stabilize hemodynamics, making this a less urgent intervention in this acute scenario.
Choice C reason: IV morphine relieves pain and anxiety in pulmonary embolism but does not address the primary issue of hypoxemia. Oxygen therapy is critical to correct low oxygen saturation, preventing organ damage, making morphine a secondary intervention compared to the immediate need for oxygenation.
Choice D reason: Cardiac monitoring is important to detect arrhythmias in pulmonary embolism but is not the priority over oxygen therapy. Hypoxemia is the immediate life-threatening issue, requiring oxygen to restore gas exchange, making monitoring a supportive, not primary, intervention in the acute management of this condition.
Correct Answer is ["C","D","E"]
Explanation
Choice A reason: Measuring thighs monitors edema but is not a preventive intervention for venous thromboembolism. Active measures like leg exercises and compression stockings directly reduce clotting risk, making this incorrect, as it is a monitoring, not preventive, action in the postoperative care plan.
Choice B reason: Massaging calves is contraindicated in venous thromboembolism risk, as it may dislodge clots, causing embolism. Preventive measures like exercise and compression are safer, making this incorrect, as massage increases harm risk rather than preventing thrombosis in postoperative clients.
Choice C reason: Frequent leg exercises activate the muscle pump, promoting venous return and reducing stasis, a key factor in venous thromboembolism prevention. This is a critical intervention for postoperative clients, making it a correct choice to include in the care plan to lower clotting risk.
Choice D reason: Encouraging fluid intake prevents dehydration, which increases blood viscosity and clotting risk. Adequate hydration supports circulation, reducing venous thromboembolism risk in postoperative clients, making this a correct intervention to include in the care plan for effective prevention.
Choice E reason: Elastic compression stockings apply graduated pressure, enhancing venous return and preventing stasis, a major risk factor for venous thromboembolism. This is a standard postoperative intervention, making it a correct choice to include in the care plan to reduce clotting risk.
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