Compare an actual nursing diagnosis with a risk for nursing diagnosis, recognizing that in the case of the actual nursing diagnosis

the patient is vulnerable to develop the problem

there is no evidence of defining characteristics

a condition is currently present

it is written as a two-part statement

Answer and Explanation

The Correct Answer is C

A. The patient is vulnerable to develop the problem: This describes a risk diagnosis, where the patient has the potential to develop a condition but does not currently have it.

B. There is no evidence of defining characteristics: An actual nursing diagnosis must have defining characteristics (symptoms/signs).

C. A condition is currently present: An actual nursing diagnosis means the condition is already present, with observable signs and symptoms.

D. It is written as a two-part statement: Actual nursing diagnoses use a three-part statement:

Problem (diagnosis)
Etiology (cause)
Signs and Symptoms (evidence)

Nursing Test Bank

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Correct Answer is D

Explanation

A. Physician's Order Sheet: While the physician orders narcotics, administration is not documented here.

B. Narcotic Administration Sheet: The Narcotic Administration Sheet is specifically for controlled substances, ensuring proper tracking and preventing misuse.

C. Care Plan: The care plan outlines patient goals and interventions, not medication administration.

D. MAR (Medication Administration Record) and Narcotic Administration Sheet: The MAR (Medication Administration Record) documents all medications given to the patient. The Narcotic Administration Sheet is required for controlled substances to comply with regulations.

A. patient's vital signs are B/P 120/80, P 88 and R 18 B. non-responsive patient C. disoriented patient D. critically patient ill

Correct Answer is A

Explanation

A. Patient’s vital signs are B/P 120/80, P 88, and R 18: Stable, normal vital signs do not indicate an immediate need for a focused assessment unless there is a complaint or concern.

B. Non-responsive patient: A focused neurological and airway assessment is required for an unresponsive patient.

C. Disoriented patient: Disorientation may indicate neurological issues, infection, or metabolic imbalance, requiring a focused mental status and neurological assessment.

D. Critically ill patient: Critically ill patients require frequent focused assessments based on their condition (e.g., respiratory, cardiac, or neurological).

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Compare an actual nursing diagnosis with a risk for nursing diagnosis, recognizing that in the case of the actual nursing diagnosis

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

On what form/forms should the nurse chart when administering a narcotic?

Correct Answer is D

Explanation

A focused assessment should be done by the nurse in all of the following situations EXCEPT:

Correct Answer is A

Explanation

Who should document care in the patient record?

In which step of the nursing process do nurses look at outcomes?

When documenting events in a patient's chart, the nurse should chart:

Which of the following assists the nurse in the identification of nursing diagnoses?

The patient with a urinary tract infection is being assessed using a critical pathway. When a projected outcome is not met by a predetermined date it is determined that a/an:

The nurse administered the stat insulin dose as ordered, in the presence of the nurse's aide and the dietary aide, however, the nurse failed to chart the medication on the MAR. During a legal deposition regarding charges of professional malpractice, it was determined that:

The nurse is trying to decide what interventions will assist the patient with dyspnea to meet needs demonstrated by the patient. This phase of the nursing process is:

The patient with a nursing diagnosis of airway clearance, ineffective, might have a desired patient outcome of: