Which statement best describes the relationship between nursing diagnosis and medical diagnosis?

Answer: b
The patient's condition requires immediate performance of the lifesaving steps of the nursing process. All other answers are secondary actions. The nurse later resumes all interventions for previously identified nursing diagnoses and evaluates the success of the acute care plan for management of the cardiac arrest. Nurses do not seek the input of the physician for creation of nursing diagnoses.
LO: 7.5
Blooms: Analyzing
TOP: Nursing process
MSC: NCLEX Client Needs: Safe and effective care environment: Teaching and learning

10. What signs and symptoms would the nurse appropriately cluster for a patient with extreme anxiety? (Select all that apply.)
a. Denies any difficulty falling asleep
b. Elevated pulse rate auscultated at 140 BPM
c. Continuous foot tapping throughout intake interview
d. Demonstrates how to give insulin self-injection without hesitation
e. Patient states, "I feel nervous all the time, especially when I am alone."
Answer: b, c, e
An elevated pulse rate, continuous toe tapping, and verbalizing nervousness are consistent with extreme anxiety and should be clustered together. Ease of falling asleep and being able to focus on a challenging task, such as giving an injection, are not indicative of a patient experiencing a high level of anxiety.
LO: 7.5

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