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. "Risk for infection related to chest x-ray procedure" is not an appropriate diagnosis because a chest x-ray is a diagnostic tool, and pneumonia itself is the concern for infection.
B. "Impaired gas exchange related to alveolar-capillary membrane changes" is correct as pneumonia causes inflammation and consolidation in the lungs, which directly impacts gas exchange.
C. "Risk for deficient fluid volume related to dehydration" does not apply specifically to pneumonia unless the patient presents signs of dehydration, which is not indicated in the scenario.
D. "Ineffective breathing pattern related to pneumonia" could also be a valid diagnosis, but the primary concern given the information provided is gas exchange impairment.

A. The nurse stayed within the guidelines of the Good Samaritan Law. B. The nurse acted appropriately and saved the patient's life. C. The nurse should have just stayed with the patient and waited for help. D. The nurse took actions beyond those that are standard and appropriate.

Correct Answer is D

Explanation

A. The Good Samaritan Law typically protects individuals who provide care in emergency situations but may not apply if the actions taken are beyond the standard of care or are not in the nurse's training.
B. While the nurse's intention was to save the patient's life, the method employed was not a recognized standard procedure for airway management and may have caused harm.
C. Waiting for help may not have been an appropriate option if the patient's airway was compromised, but the method employed by the nurse was not advisable.
D. Cutting into the trachea and using a straw as a makeshift airway are actions that exceed the typical scope of nursing practice and could be deemed inappropriate, regardless of the outcome for the patient.

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Naxlex Comprehensive Predictor Exams

A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

A nurse is assessing a patient with prolonged stress. Which conditions will the nurse monitor for in this patient? (Select all that apply.)

Which patients will the nurse determine are in most need of regular perineal care? (Select all that apply.)

A nurse caring for a patient prescribed warfarin discovers that the patient is taking garlic to help with hypertension. Which condition will the nurse assess for in this patient?

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

The patient must stay in bed for a bed change. Which actions will the nurse implement? (Select all that apply.)

A nurse makes a connection with the patient when providing spiritual care. Which type of connectedness did the nurse experience?

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?