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 B

Explanation

A. Temperature and bowel sounds are measurable, making them objective data rather than subjective.

B. These symptoms cannot be measured or observed by the nurse; they are based on the patient's personal experience, making them subjective data.

C. While the cough is subjective, the respiratory rate is measurable and therefore objective. Since the option includes both types of data, it is not the best answer.

D. White blood cell count is objective. Pain rating is subjective, but since this option includes both types of data, it is not the best choice.

A. Risk B. Actual C. Syndrome D. Wellness

Correct Answer is B

Explanation

A. A risk diagnosis applies when a problem has not yet occurred but is likely. This patient is already experiencing chest pain and hemodynamic instability, requiring an actual diagnosis.

B. The patient has current symptoms of chest pain, sweating, pallor, hypotension, and an irregular pulse, indicating a medical condition (possibly myocardial infarction). This justifies an actual diagnosis.

C. Syndrome diagnoses involve a cluster of related diagnoses, such as frail elderly syndrome. This patient’s case does not meet that definition.

D. Wellness diagnoses focus on improving health, not addressing an active medical crisis.

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

Explanation

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 is B

Explanation

When should a nurse perform an ongoing assessment during a patient's hospital stay?

A 65-year-old male patient with hypertension was recently started on a new antihypertensive medication. During the evaluation phase of the nursing process, which action should the nurse prioritize?

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)?

When using the PIE format for documentation, which of the following elements should the nurse include under 'P?

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?

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?

A nurse receives change of shift report about a group of assigned patients. Which patient should the nurse attend to first?

The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?