Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved?

Acute pain

Sore throat

Sleep apnea

Heart failure

Answer and Explanation

The Correct Answer is A

A. "Acute pain" is a NANDA-I approved nursing diagnosis that identifies a specific condition that nursing interventions can address.
B. "Sore throat" is a symptom rather than a nursing diagnosis and does not appear in NANDA-I.
C. "Sleep apnea" is classified as a medical diagnosis and not as a nursing diagnosis within NANDA-I.
D. "Heart failure" is also a medical diagnosis and not an approved nursing diagnosis, as it describes a condition rather than the patient's response or nursing concerns.

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Correct Answer is C

Explanation

A. While monitoring cardiac output can provide insights into heart function, it does not directly determine the presence of dysrhythmias.
B. Peripheral extremity circulation is influenced by cardiac output but is not the primary focus of monitoring it.
C. Cardiac output is essential for determining the heart's ability to meet the body's oxygenation requirements; low cardiac output can lead to inadequate oxygen delivery.
D. Ventilation status refers to the respiratory function and is not directly assessed through cardiac output measurements.

A. Cardiac B. Neurological C. Gastrointestinal D. Respiratory

Correct Answer is A

Explanation

A. Hyperkalemia can lead to dangerous cardiac arrhythmias and other heart-related complications due to its effect on the electrical conduction system of the heart, making cardiac assessment the priority.
B. While neurological assessment is important in various conditions, it is secondary to assessing cardiac status in hyperkalemia.
C. Gastrointestinal symptoms can occur with hyperkalemia, but they do not pose an immediate life-threatening risk like cardiac issues do.
D. Respiratory assessment is essential in many contexts, but the immediate threat of hyperkalemia lies in its impact on heart function, making cardiac assessment the most critical.

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Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which determination is the nurse trying to achieve by monitoring a patient's cardiac output?

Correct Answer is C

Explanation

The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority?

Correct Answer is A

Explanation

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