A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?

Health promotion

Risk

Problem focused

Collaborative problem

Answer and Explanation

The Correct Answer is A

A. "Readiness for enhanced urinary elimination" is classified as a health promotion diagnosis, indicating the patient’s desire to improve their health condition and adopt new health behaviors.
B. A risk diagnosis is used when there is a potential for problems to occur, not applicable in this scenario as the patient is actively seeking improvement.
C. A problem-focused diagnosis describes an existing problem that requires intervention; this situation reflects readiness for improvement, not an existing issue.
D. A collaborative problem involves potential complications that require both nursing and medical management; this case focuses on the patient's willingness to learn a self-management skill rather than managing a specific medical problem.

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Correct Answer is B

Explanation

A. While anxiety may contribute to hyperventilation, in the context of a febrile child, the primary factor is usually metabolic.
B. Increased metabolic demands due to fever can elevate the body’s oxygen requirements, prompting hyperventilation as a compensatory mechanism.
C. Decreased drive to breathe would not lead to hyperventilation; rather, it might result in hypoventilation or respiratory distress.
D. Infection destroying lung tissues would typically lead to respiratory distress or failure, not directly cause hyperventilation without the context of increased metabolic needs.

A. Patient will increase activity level this shift. B. Patient will turn side to back to side with assistance every 2 hours. C. Patient will use the walker correctly to ambulate to the bathroom as needed. D. Patient will use a sliding board correctly to transfer to the bedside commode as needed.

Correct Answer is B

Explanation

A. Increasing activity level may be unrealistic for a patient on strict bed rest due to a pelvic fracture.
B. Repositioning every 2 hours is a realistic and achievable goal for a patient on bed rest to prevent complications such as pressure ulcers and maintain circulation.
C. Using a walker for ambulation may not be feasible immediately after a pelvic fracture.
D. Transferring with a sliding board may not be safe or appropriate in the early stages post-injury, especially if bed rest is required.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation?

Correct Answer is B

Explanation

A nurse is developing a care plan for a patient prescribed bed rest as a result of a pelvic fracture. Which goal statement is realistic for the nurse to assign to this patient?

Correct Answer is B

Explanation

The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the patient says, "I always bathe in the evening." Which action by the nurse is best?

A nurse is caring for a group of patients. Which patient should the nurse see first?

The nurse has received a report from the emergency department that a patient with tuberculosis will be coming to the unit. Which items will the nurse need to care for this patient? (Select all that apply.)

A co-worker asks the nurse to explain spirituality. What is the nurse's best response?

A patient requires repositioning every 2 hours. Which task can the nurse delegate to the nursing assistive personnel?

The nurse and the patient have the same religious affiliation. Which action will the nurse take to support the patient spiritually?

A nurse is teaching a health class about the heart. Which information from the class members indicates teaching by the nurse is successful for the flow of blood through the heart, starting in the right atrium?