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 C
Explanation
Choice A rationale
This is a closed-ended question that requires a yes or no answer. While it gathers specific information about breathing difficulty, it limits the patient's ability to describe their chest pain experience in their own words and provide richer details.
Choice B rationale
This question focuses on the duration of the chest pain. While this is important information for the nurse to know, it does not elicit a description of the pain itself, which is crucial for understanding the potential underlying cause and guiding further assessment.
Choice C rationale
This open-ended question encourages the patient to describe the characteristics of their chest pain, such as its quality (e.g., sharp, dull, crushing), location, radiation, and intensity. This detailed information is vital for differentiating between various causes of chest pain, including cardiac, musculoskeletal, or gastrointestinal issues.
Choice D rationale
While family history is relevant to the patient's overall health status and potential risk factors for certain conditions like heart disease, it does not directly address the patient's immediate experience of chest pain or provide details about the current symptom.
Correct Answer is C
Explanation
Choice A rationale
SBAR (Situation, Background, Assessment, Recommendation) is a structured communication tool used for verbal or written reports, focusing on concise information transfer during transitions of care or urgent situations, not a comprehensive charting system based on exceptions.
Choice B rationale
Focused charting centers on specific patient problems or concerns, using a DAR (Data, Action, Response) format. It addresses particular issues in detail rather than documenting only deviations from the norm.
Choice C rationale
Charting by exception (CBE) is a documentation system where nurses only document findings that are outside the normal range or significant changes in a patient's condition. Standardized care and expected outcomes are assumed to be met and are not routinely documented, saving time and reducing redundancy.
Choice D rationale
SOAP (Subjective, Objective, Assessment, Plan) is a problem-oriented charting method commonly used by physicians and other healthcare providers to organize patient information around specific problems identified during assessment.
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