An example of an appropriate nursing diagnosis is:
Patient will report increased activity tolerance within 4 days.
Patient will have improved nutritional intake in 3 days, as evidenced by eating 75% of a protein-rich meal and a 1-1.5 lb weight gain.
Impaired physical mobility related to extreme weakness as evidenced by the inability to perform active ROM exercises, inability to transfer from bed to chair, and use of a walker when ambulating.
Impaired skin integrity due to the patient being lazy as evidenced by a 5cm x 2cm x 1/2 cm stage III ulcer noted on the coccyx, an unstageable wound on the left heel, and a reddened area on the right elbow.
The Correct Answer is C
Choice A rationale
This statement is written as a patient outcome, not a nursing diagnosis. A nursing diagnosis identifies a patient problem based on assessment data. Outcome statements describe the desired change in patient status as a result of nursing interventions and should be specific, measurable, achievable, relevant, and time-bound (SMART).
Choice B rationale
Similar to Choice A, this statement describes a desired patient outcome with specific criteria. While it includes evidence of improvement, it does not identify the underlying nursing diagnosis or the "related to" factor causing the potential nutritional deficit. A nursing diagnosis requires identifying the problem, its cause, and supporting evidence.
Choice C rationale
This statement correctly identifies a nursing diagnosis with three parts: the problem ("Impaired physical mobility"), the etiology or related factor ("related to extreme weakness"), and the supporting evidence ("as evidenced by the inability to perform active ROM exercises, inability to transfer from bed to chair, and use of a walker when ambulating"). This structure is characteristic of an accurate nursing diagnosis.
Choice D rationale
This statement presents an inaccurate and judgmental related factor ("due to the patient being lazy"). Nursing diagnoses should be based on physiological, psychological, sociological, or spiritual responses to health conditions or life processes, not on subjective or potentially stigmatizing attributions. Additionally, the evidence provided describes the skin breakdown but the stated cause is inappropriate and unprofessional.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
"Seems lethargic" is subjective and lacks specific, measurable data. Lethargy can manifest differently in patients, and this statement doesn't provide objective evidence to support the observation. Accurate documentation requires specific descriptions of observed behavior.
Choice B rationale
"The patient was incontinent" is more direct but lacks crucial details such as the type of incontinence (urinary or fecal), the amount, and any associated factors. Comprehensive documentation would include these specifics for a clear understanding of the event.
Choice C rationale
"The patient ate 25% of a hearty meal" is relatively objective and quantifiable, providing a specific measure of the patient's intake. However, "hearty" is still somewhat subjective. Specifying the type and estimated size of the meal would enhance clarity.
Choice D rationale
"The patient voided in the urinal" is a clear, objective statement of an observable action. It specifies the method of voiding and provides a concrete piece of information about the patient's urinary function. This type of documentation is precise and unambiguous.
Correct Answer is C
Explanation
Choice A rationale
Information about the family of a client in a different room (room 107) is not directly relevant to the change-of-shift report for the client in room 108. The report should focus on information pertinent to the care of the assigned client.
Choice B rationale
While the fact that a client in room 105 had a bath might be included in their specific report, it is not essential information to communicate during the change-of-shift report for the client in room 108 who has a new pain medication.
Choice C rationale
The administration of a new pain medication to the client in room 108 is crucial information for the oncoming nurse. It is essential to communicate the name of the medication, the time it was given, the dosage, the route of administration, and the client's response to the medication to ensure continuity of pain management.
Choice D rationale
The dietary preferences of a client in a different room (room 109) are not relevant to the change-of-shift report for the client in room 108. Dietary information is specific to each client and should be communicated within their individual report if pertinent to their current care.
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