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

A.

Acute pain

B.

Sore throat

C.

Sleep apnea

D.

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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Related Questions

Correct Answer is D

Explanation

A. Grief evaluation refers to assessing the grief process rather than actively engaging in supportive dialogue, which is not the primary focus of the nurse's action.
B. Pain-management techniques would not apply directly to this context, as the discussion centers on emotional support rather than physical pain.
C. Palliative care encompasses a broader approach to managing patients with serious illnesses but does not specifically address the emotional support provided in this situation.
D. The nurse's action of discussing the child's life and death helps the parents express their grief and memories, thereby facilitating normal mourning, making this the most appropriate principle demonstrated.

Correct Answer is B

Explanation

A. While anxiety may contribute to hyperventilation, in the context of a febrile child, the primary factor is usually metabolic.
B. Increased metabolic demands due to fever can elevate the body’s oxygen requirements, prompting hyperventilation as a compensatory mechanism.
C. Decreased drive to breathe would not lead to hyperventilation; rather, it might result in hypoventilation or respiratory distress.
D. Infection destroying lung tissues would typically lead to respiratory distress or failure, not directly cause hyperventilation without the context of increased metabolic needs.

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