Nurse Angela, observe Joel who is very apprehensive over the impending operation. The client is experiencing dyspnea, diaphoresis and asks lots of questions. Angela made a diagnosis of ANXIETY R/T INTRUSIVE PROCEDURE. This is what type of Nursing Diagnosis?

Correct Answer: A

Rationale: Angela's diagnosis 'Anxiety R/T intrusive procedure' is actual (A); Joel's dyspnea, diaphoresis, and questions are present signs, per NANDA. Probable (B) and possible (C) lack evidence, risk (D) predicts. A matches current data, making it correct.

Correct Answer: C

Rationale: Referred pain is felt distant from its source, like shoulder pain with myocardial infarction (MI) (C), per nerve pathway convergence (e.g., diaphragm to shoulder). Stump pain (A) is phantom, surgical site (B) and fracture (D) are local. C exemplifies referred pain's mislocation, making it correct.

Correct Answer: D

Rationale: Death rattle in Mr. Gary results from pooling secretions (A), lost cough reflex (B), and muscle tone loss (C) all (D), per terminal signs. Secretions accumulate, un-cleared due to weak reflexes and muscles, causing rattling. All contribute, making D the correct comprehensive cause.

Correct Answer: C

Rationale: Autopsy isn't done in all deaths (C) untrue; only specific cases (e.g., unclear cause), per protocol. Consent (A), cause (B), and future help (D) are true. C's universality fails, making it the untrue statement.

Correct Answer: A

Rationale: Forcing medication on refusing Mr. Gary violates autonomy (A) self-determination, per ethics. Beneficence (B) does good, justice (C) fairness, nonmaleficence (D) avoids harm not choice-based. A's breach of consent makes it correct.