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 pneumonia. This activity contains 7 questions. (15 scores) 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) 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 score) 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? (2 scores) 1. 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 score) 1. 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 (7 scores) -nin non 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.

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 pneumonia.

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.

2.

3.

4.

5.

6.

7.

Answer 1

1. Ineffective airway clearance related to thick secretion.

2.impaired physical mobility replayed to contractures secondary to  disease condition.

Impaired skin Integrity retaliated to immobility secondary to contractures.

3. Risk of dehydration due to increased body temperature and sweating.

4. Self-Care Deficit: Impaired ability to perform or complete activities of daily living for oneself, such as feeding,

5. Impaired swallowing due to coughing and dyspnoea secondary to pneumonia.

6.impaired physical mobility due to decreased strength

B.impaired skin Integrity   

C.impaired sleep pattern

D.self care deficit to feeding.

E.anxiety

F.pain related to disease condition

G ineffective breathing pattern

H activity intolerance   

I

7.

The goals of interventions are to avoid the hazards of immobility, prevent dependent disabilities, and assist the patient in restoring, preserving, or maintaining as much mobility and functional independence as possible, as evidenced by the following indicators:

• Patient performs physical activity independently or within limits of disease.
• Patient demonstrates measures to increase mobility
• Patient demonstrates the use of adaptive devices to increase mobility
• Patient evaluates pain and quality of management
• Patient uses safety measures to minimize potential for injury
• Patient is free from complications of immobility, as evidenced by intact skin, absence of thrombophlebitis, normal bowel pattern, and clear breath sounds.