A nurse receives a patient who has been in the intensive care unit for three weeks after a motor vehicle accident. The nurse assesses the patient who reports fatigue. The nurse notes increased heart rate and decreased blood pressure when the patient moves from lying to sitting. When developing the plan of care. what problem label should the nurse use?

Risk for alteration in skin integrity

Activity Intolerance

Risk for Infection

Deficient Fluid volume

Answer and Explanation

The Correct Answer is B

A. While long-term immobility increases the risk of skin breakdown, this is not the primary concern in this scenario.

B. The patient exhibits fatigue, increased heart rate, and orthostatic hypotension, indicating reduced ability to tolerate physical activity, making Activity Intolerance the most appropriate diagnosis.

C. While ICU patients may be at risk for infection, there is no evidence of active infection in this scenario.

D. Orthostatic hypotension can be linked to dehydration, but the case does not provide enough information to confirm a fluid volume deficit.

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Correct Answer is C

Explanation

A. Increased pain and frequent falls indicate unmet outcomes.
B. Frequent falls indicate unmet outcomes.
C. This demonstrates progress toward independence in mobility.
D. Difficulty ambulating shows ongoing impairment.

A. "Is this your first time experiencing these symptoms?" B. "Do you have any allergies?" C. "Can you describe what brought you to the hospital today?" D. "Are you feeling any pain right now?"

Correct Answer is C

Explanation

A. This is a closed-ended question that leads to a simple "yes" or "no" response, limiting the amount of information the nurse gathers.

B. While this is important information, it is not an appropriate opening question for a full nursing assessment, as it does not encourage the patient to share their primary concern.

C. This open-ended question allows the patient to provide a detailed narrative, helping the nurse gather a comprehensive history.

D. This is a closed-ended question that focuses only on pain rather than encouraging the patient to share their full reason for seeking care.

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Naxlex Comprehensive Predictor Exams

The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?

Correct Answer is C

Explanation

Which of the following is the most appropriate open-ended question to begin a nursing assessment?

Correct Answer is C

Explanation

A nurse takes a health history, measures vital signs and conducts a physical assessment on a new admission. After data analysis, what should the nurse do next?

Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient?

A patient who recently underwent abdominal surgery is complaining of severe abdominal pain and has a distended abdomen. Which of the following interventions should the nurse do first?

Which of the following signs is most indicative of impaired skin integrity?

A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?

A nurse formulates several nursing diagnoses then prioritizes using Maslow's hierarchy. What nursing diagnosis should have the highest priority?

The nurse is providing care to a client admitted with pressure injuries. The nurse develops a plan of care focusing on healing measures and prevention of further injury. Which task does the nurse delegate to the nursing assistive personnel (NAP)?

A nurse reviews a patient's health record and finds the following data. Which example includes only subjective data?