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 B
Explanation
Choice A rationale
"The patient is sleeping comfortably" is a subjective observation and does not provide a quantifiable measure of the patient's pain level. While comfort is important, this statement lacks specific information about the patient's pain experience and does not allow for consistent monitoring or evaluation of pain management interventions.
Choice B rationale
"The patient rated the pain at 2 on a 0-to-10 scale" is an example of appropriate pain assessment documentation. It uses a standardized pain scale, allowing the patient to quantify their pain intensity. This provides objective data that can be used to monitor changes in pain levels over time and evaluate the effectiveness of pain management strategies.
Choice C rationale
"The patient appears not to be in any pain" is a subjective interpretation by the nurse based on observation. It does not involve input from the patient about their pain experience. Pain is subjective, and a patient may be experiencing pain even if they do not outwardly appear to be in distress. Relying solely on observation can lead to underreporting and undertreatment of pain.
Choice D rationale
"The patient always complains about being in pain" is a generalization and does not provide specific information about the patient's current pain level. It can also introduce bias into future pain assessments. Each pain report should be documented objectively and based on the patient's current experience, not past complaints.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Determining the client's goals and expectations regarding hospitalization is crucial for patient-centered care. Understanding what the client hopes to achieve during their stay allows the nurse to tailor the care plan to meet their individual needs and preferences, promoting adherence and satisfaction.
Choice B rationale
Establishing a therapeutic relationship with the client and their wife is fundamental for effective communication and trust. A strong rapport facilitates open dialogue, allowing the nurse to gather accurate information, provide emotional support, and involve the family in the care process.
Choice C rationale
Identifying the client's chief complaints, concerns, and worries is the primary focus of the initial interview. Understanding the main reasons for seeking healthcare helps the nurse to prioritize assessments and interventions, addressing the most pressing issues first.
Choice D rationale
Ascertaining which parts of the interview may require further exploration guides subsequent data collection. Identifying areas where more detailed information is needed ensures a comprehensive understanding of the client's health status and allows the nurse to focus on relevant aspects in follow-up interactions.
Choice E rationale
While reviewing the client's past medical history is important, it is usually a more detailed process that occurs after the initial interview to identify immediate concerns. The initial interview focuses on the present situation and the client's current perspective.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.