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. While teamwork is crucial, patient input should come first to ensure the plan aligns with their needs and capabilities.

B. Family involvement is beneficial, but the patient should have the primary role in decision-making.

C. Effective discharge planning is patient-centered, ensuring that goals align with their preferences, abilities, and resources.

D. Although discharge planning should begin at admission, the most important factor for success is patient involvement.

A. As written, the diagnosis is too complex. B. The staff nurse is being judgmental. C. The diagnosis is legally questionable. D. There is deficiency of supportive data.

Correct Answer is B

Explanation

A. The diagnosis is not necessarily complex.

B. Nursing diagnoses should be objective and free from judgment. "Laziness" is subjective and inappropriate.

C. No legal issue is present, but professionalism is lacking.

D. The issue is more about the judgmental phrasing than missing data.

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Naxlex Comprehensive Predictor Exams

The nurse begins discharge planning for an older adult with left-side weakness. Which action is most important in ensuring that the discharge plan is successful?

Correct Answer is C

Explanation

The nurse manager notices that a staff nurse writes a nursing diagnosis as "Impaired Physical Mobility, related to laziness and not having appropriate shoes." Which issue related to the nursing diagnosis will the nurse manager discuss with the staff nurse?

Correct Answer is B

Explanation

The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?

After receiving change of shift report, the nurse delegates hygiene care for the caseload of patients. Which patient should the nurse delegate to the nursing assistive personnel (NAP)?

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

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?

Which patient scenario of a surgical patient in pain is most indicative of critical thinking?

The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?

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?

A nurse educator is reviewing guidelines for writing an outcome statement. Which examples best indicate a correct outcome statement? (Select All that Apply.)