Complete the following sentence by using the list of options.
A clinical judgement about individual, family, or community responses to actual or potential health problems/life process is known as a:
medical diagnosis.
nursing diagnosis.
collaborative problem.
physician's order.
The Correct Answer is B
Choice A rationale
A medical diagnosis identifies a specific disease or pathological process based on signs, symptoms, diagnostic tests, and medical history. It focuses on the disease itself and its etiology, which differs from evaluating a patient's response to health issues.
Choice B rationale
A nursing diagnosis is a clinical judgment concerning a human response to health conditions, life processes, or vulnerability for that response by an individual, family, group, or community. It provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.
Choice C rationale
A collaborative problem is a potential or actual physiological complication that nurses monitor to detect the onset of changes in a patient’s status. These problems require both nurse-prescribed and physician-prescribed interventions, focusing on managing potential complications rather than the response itself.
Choice D rationale
A physician's order is a directive from a medical doctor or other legally recognized healthcare provider that outlines specific treatments, medications, tests, or other interventions for a patient. It guides medical care, not the identification of patient responses.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Performing a focused patient assessment at the beginning of the shift is the priority action as it allows the nurse to gather current data about the patient's condition. This assessment provides the foundation for identifying the patient's immediate needs, establishing priorities, and planning appropriate care for the shift. It ensures that any changes in the patient's status since the last shift are promptly identified and addressed.
Choice B rationale
Administering prescribed medication is an important nursing responsibility, but it should occur after the initial assessment. The assessment may reveal changes in the patient's condition that could affect the timing or appropriateness of medication administration. Prioritizing assessment ensures medication administration is safe and based on the most current patient data.
Choice C rationale
Creating the nursing plan of care is an ongoing process that is informed by the initial and subsequent patient assessments. While a plan of care guides nursing interventions, the immediate need at the start of the shift is to assess the patient's current status to ensure the plan remains relevant and addresses any new or changing needs.
Choice D rationale
Determining the patient's family history is typically part of the comprehensive admission assessment. While relevant for understanding the patient's overall health risks, it is not the priority action at the beginning of each shift. The immediate focus should be on the patient's current physical and emotional status to guide immediate care.
Correct Answer is ["9.6"]
Explanation
Step 1 is: Locate the section on the Penicillin G label that provides reconstitution instructions for intramuscular (IM) injection.
Step 2 is: Identify the desired dose of Penicillin G, which is 350,000 units.
Step 3 is: Examine the label to find the different dilution options and the resulting concentration (units/mL) for IM administration. The label provides the following reconstitution guidelines for IM injection:. Add 9.6 mL of sterile water for injection to yield 1,000,000 units/mL (Total volume: 10 mL). Add 4.6 mL of sterile water for injection to yield 2,000,000 units/mL (Total volume: 5 mL).
Step 4 is: Determine which dilution would be most appropriate for administering 350,000 units. Using the 1,000,000 units/mL concentration:. Volume to administer = Desired dose ÷ Concentration. Volume to administer = 350,000 units ÷ 1,000,000 units/mL = 0.35 mL. Using the 2,000,000 units/mL concentration:. Volume to administer = Desired dose ÷ Concentration. Volume to administer = 350,000 units ÷ 2,000,000 units/mL = 0.175 mL.
Step 5 is: Consider the practicalities of administering such small volumes. While both are technically correct, administering 0.35 mL is generally easier and more accurate than 0.175 mL with standard syringes. Therefore, diluting to yield 1,000,000 units/mL is the more appropriate choice. The question asks for the most appropriate diluent amount, which corresponds to this concentration. To achieve a concentration of 1,000,000 units/mL, 9.6 mL of diluent should be added.
Final Answer: The most appropriate diluent amount is 9.6 mL of sterile water for injection to yield a concentration of 1,000,000 units/mL, and then administer 0.35 mL.
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