A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?

Risk for infection related to chest x-ray procedure

Impaired gas exchange related to alveolar-capillary membrane changes

Risk for deficient fluid volume related to dehydration

Ineffective breathing pattern related to pneumonia

Answer and Explanation

The Correct Answer is B

A. "Risk for infection related to chest x-ray procedure" is not an appropriate diagnosis because a chest x-ray is a diagnostic tool, and pneumonia itself is the concern for infection.
B. "Impaired gas exchange related to alveolar-capillary membrane changes" is correct as pneumonia causes inflammation and consolidation in the lungs, which directly impacts gas exchange.
C. "Risk for deficient fluid volume related to dehydration" does not apply specifically to pneumonia unless the patient presents signs of dehydration, which is not indicated in the scenario.
D. "Ineffective breathing pattern related to pneumonia" could also be a valid diagnosis, but the primary concern given the information provided is gas exchange impairment.

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Correct Answer is A

Explanation

A. Regular engagement in meditation for 10 minutes daily indicates effective learning and practice of meditation techniques, as consistency is key to developing this skill.
B. Breathing quickly is not indicative of effective meditation, as the practice typically involves slow, deep breathing to promote relaxation.
C. While lying on the floor can be a comfortable position for some, it does not specifically indicate effective learning in meditation, as it depends on the individual’s preferences.
D. Focusing on a particular image can be a part of meditation but does not solely demonstrate effective learning without the context of regular practice and the correct breathing techniques.

A. Each movement is performed until the patient reports pain. B. Each movement is moved just to the point of resistance by the nurse. C. Each movement is repeated 5 times by the patient. D. Each movement is completed quickly and smoothly by the nurse.

Correct Answer is B

Explanation

A. Performing movements until the patient reports pain is inappropriate in passive range of motion, as the goal is to maintain joint function without causing discomfort.
B. Moving each joint to the point of resistance helps to maintain flexibility and prevent stiffness without causing harm, making this the appropriate technique.
C. Repeating movements five times by the patient is not applicable for passive range of motion, which is performed by the nurse on a patient who cannot do it themselves.
D. While smooth movements are essential, they should not be done quickly; the focus should be on the patient's comfort and safety, avoiding rapid or jerky motions.

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A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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