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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale

While documentation can be reviewed by providers, its primary purpose is not to monitor nurses' performance. Monitoring occurs through various quality assurance processes, and documentation serves a broader range of functions beyond individual nurse oversight.

Choice B rationale

Documentation acts as a central communication hub for all members of the healthcare team, including physicians, nurses, therapists, and other specialists. It ensures continuity of care by providing a shared understanding of the client's condition, treatments, and responses, facilitating informed decision-making and collaboration.

Choice C rationale

Although documentation can be used for audits, such as financial or quality audits, this is not its primary purpose. The main goal of documentation is to provide a comprehensive record of patient care for effective communication and continuity.

Choice D rationale

While accurate documentation supports billing and reimbursement processes from various payers, including government entities, this is a secondary outcome. The primary aim of documentation is to ensure high-quality patient care through clear and comprehensive information sharing.

A. Read back the order to the physician for confirmation. B. Double-check the order with another registered nurse. C. Authorize the physician's order with the pharmacy. D. Withhold the medication until the physician signs the order.

Correct Answer is A

Explanation

Choice A rationale

Reading back the order ensures accuracy and allows the physician to immediately correct any misheard or misinterpreted information. This step is crucial for patient safety as it verifies the details of the medication order before it is implemented.

Choice B rationale

While double-checking with another nurse is a good practice, the immediate priority after receiving a telephone order is to confirm the order directly with the prescriber to avoid any initial misunderstanding.

Choice C rationale

Authorizing the order with the pharmacy occurs after the order has been received and verified. The pharmacy then prepares and dispenses the medication based on the confirmed order.

Choice D rationale

Withholding the medication could delay necessary treatment. The priority is to verify the order promptly and then proceed with safe administration. Many institutions allow for a limited time frame for the written order to follow a telephone order.

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An example of an appropriate nursing diagnosis is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to document a client's information in the electronic medical record.Which of the following nursing statements identifies the purpose of documentation?

Correct Answer is B

Explanation

What is the priority action of the nurse immediately after receiving a medication telephone order from a physician?

Correct Answer is A

Explanation

The nurse is caring for a nonverbal client who is moaning with position changes, the hands and teeth are clenched, and the skin is very diaphoretic.The nurse interprets this as the client is experiencing pain and decides to administer an analgesic.What is the correct term for this nursing action?

Which nursing diagnosis is the highest priority for a patient with pneumonia?

An example of an appropriate nursing diagnosis is:

The nursing process is best defined as a framework for the organization of individualized nursing care.

Which patient's needs must be addressed first by the nurse?

The nurse is caring for a patient who came to the hospital with acute shortness of breath.What is the priority action of the nurse as the assessment process is started?