A nursing student correctly describes a risk diagnosis by which of the following statements?

A problem that the client is currently experiencing.

A situation in which a problem will likely occur if the nurse does not intervene.

Those situations in which the client does not have a problem but is at a point in which he or she can attain a higher level of health.

Clinical judgments that describe a specific cluster of nursing diagnoses that occur together and have similar interventions.

Answer and Explanation

The Correct Answer is B

A. This is incorrect because it describes an actual nursing diagnosis, not a risk diagnosis.
B. A risk diagnosis describes a situation in which a problem will likely occur if the nurse does not intervene. It identifies a potential health problem that has not yet developed but could occur due to the client’s risk factors.
C. This is incorrect because it describes a health promotion diagnosis, which focuses on enhancing well-being rather than preventing a problem.
D. This is incorrect because it describes a syndrome diagnosis, which is a group of related nursing diagnoses that occur together.

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Correct Answer is C

Explanation

A. Vesicular breath sounds are soft, low-pitched sounds heard over most of the lung fields, characterized by a longer inspiratory phase and shorter expiratory phase.
B. Adventitious breath sounds refer to abnormal breath sounds such as crackles, wheezes, and rhonchi, but the described sound is a normal breath sound in the tracheal region.
C. Bronchial breath sounds are correct. These are high-pitched, harsh sounds with a short inspiratory phase and a long expiratory phase, normally heard over the trachea.
D. Bronchovesicular breath sounds are moderate in pitch and intensity, heard over the major bronchi rather than the trachea. They have equal inspiration and expiration durations rather than a longer expiratory phase.

A. Oral mucosa B. Palms C. Sclera D. Nail beds

Correct Answer is A

Explanation

A. Oral mucosa is correct. Central cyanosis occurs when oxygen saturation is significantly reduced and is best assessed in areas with rich vascular supply, such as the oral mucosa, lips, and tongue.
B. Palms are incorrect because peripheral cyanosis (often due to cold exposure or poor circulation) can cause blue-tinged extremities, but this does not indicate central cyanosis.
C. Sclera is incorrect because cyanosis does not affect the sclera; however, jaundice does.
D. Nail beds are incorrect because, like the palms, they are more indicative of peripheral cyanosis, which can result from localized poor perfusion rather than central oxygenation problems.

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A nursing student correctly describes a risk diagnosis by which of the following statements?

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Naxlex Comprehensive Predictor Exams

While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. How would the nurse document this finding?

Correct Answer is C

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Correct Answer is A

Explanation

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