Difficulty: Medium
Average Score: 69%
Simulated
A nurse assesses a patient who reports chest pain radiating down their arm. The nurse notes the patient is sweating and pale, BP 90/50 mmHg, pulse 120bpm, irregular. When developing the plan of care, what type of nursing diagnosis should the nurse use?
Correct answer
B
Rationale
The correct answer is B: Actual. The patient is presenting with symptoms of a myocardial infarction, a life-threatening condition that requires immediate intervention. The nurse must address the current issues of chest pain, low blood pressure, tachycardia, and other concerning symptoms. Choosing a nursing diagnosis of "Actual" acknowledges the presence of these acute problems and guides the nurse in providing appropriate interventions.
Choices A, C, D, and the remaining options are not suitable in this scenario. A "Risk" diagnosis would not be appropriate as the patient is currently experiencing serious symptoms. "Syndrome" is not applicable as it does not address the acute nature of the patient's condition. "Wellness" is also not relevant as the patient is in distress and needs urgent care. Overall, selecting "Actual" as the nursing diagnosis is crucial for prioritizing immediate care and ensuring the patient's safety.
Choices A, C, D, and the remaining options are not suitable in this scenario. A "Risk" diagnosis would not be appropriate as the patient is currently experiencing serious symptoms. "Syndrome" is not applicable as it does not address the acute nature of the patient's condition. "Wellness" is also not relevant as the patient is in distress and needs urgent care. Overall, selecting "Actual" as the nursing diagnosis is crucial for prioritizing immediate care and ensuring the patient's safety.