Question

according to NANDA

A.M.S is an 18-year-old female client with profound mental retardation. A.M.S mental age is less than 3 years old. She lives at Sea Side School and is admitted to the community hospital with bilateral This activity contains 7 questions 1) The nurse notes that Ms. A.M.S coughs up thick secretions and requires oral suctioning to help clear her airway. What nursing diagnosis would you select for this problem? (2 scores) 1. 2. 2) Ms. A.M.S has severe contractures, cannot reposition herself, and can only lie on her sides. The nurse recognizes the risk for skin breakdown. What nursing diagnosis can be formulated, including the terms "related to" and "secondary to?" 1 3) Ms. A.M.S is hyperthermic, with a fever of 101 degrees F. She is NPO, but receives IV fluids and antibiotics. As her urine output decreases, the nurse recognizes the risk for dehydration. What nursing diagnosis should be used in the care plan? 1 (2 scores) 2. 4) Because of her contractures and severe mental retardation, Ms. A.M.S cannot feed herself or perform any other activities of daily living. What diagnostic statement would reflect this problem? (1 score) 1 5) Ms A.M.S is unable to ingest her usual soft diet due to coughing and dyspnea related to her pneumonia. Write a nursing diagnosis statement for this problem. 1. (1 score) 6) A thirty-five year old father of 4 young children has been admitted to home care with multiple sclerosis. He has had progressive weakness that resulted in hospitalization. In addition, he complains of muscular pain, lack of appetite, insomnia, and severe anxiety. Write a nursing diagnosis for these problems 1. (7 scores) 2. 3. 4. 5. 6. 7. 7) One of A.M.S nursing diagnoses is Impaired Physical Mobility: inability to bear weight on right leg. Ms. M will need to learn to use crutches. What goal would the nurse choose for her? (1 score) 1.

Answer 1

1, Ineffective airway clearance due to inability to clear secretions to make clear airway. due to cognitive impairments, the child can not able to remove the secretion.
2, Impaired tissue integrity related to severe contractures and secondary to immobility.
3, Fluid volume deficit due to less fluid intake.
4, self-care deficit due to physical and mental incompetence.
5, Imbalanced nutrition related to cough secondary to pneumonia.
6, -Self-care deficit related to progressive weakness and muscular pain.
-The risk for ineffective coping related to weakness and impaired mobility
-Ineffective family coping due to young children and inadequate support
-Imbalanced nutrition due to pain and lack of appetite
-impaired sleep pattern due to disease progress
-Low self-esteem due to lack of confidence about the disease and poor knowledge.
7, goal to maintain mobility without the need for assistance.