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 A
Explanation
Choice A rationale
Maslow's hierarchy of needs is a framework that prioritizes human needs in a hierarchical order, starting with physiological needs, followed by safety, love and belonging, esteem, and self-actualization. In the planning phase of nursing, this framework helps nurses to establish priorities of care by addressing the most basic and urgent needs first before moving to higher-level needs.
Choice B rationale
Piaget's cognitive developmental theory describes the stages of intellectual development in children and adolescents. While understanding cognitive development can inform nursing care, it is not the primary framework used for establishing priorities of care during the planning phase.
Choice C rationale
Erikson's stages of psychosocial development outline the social and emotional challenges individuals face across the lifespan. While relevant to understanding a client's psychosocial well-being, it is not the primary framework for prioritizing immediate nursing interventions in the planning phase.
Choice D rationale
Kohlberg's stages of moral development describe the progression of moral reasoning. While understanding a client's moral perspective can be relevant in certain situations, it is not the central framework used for establishing the priorities of physiological and safety needs in the nursing care plan. .
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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