During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin, dry mucous membranes and temperature elevation. The nurse realizes grouping this data represents:
signs of fluid overload
symptoms
data clustering
urinary retention
The Correct Answer is C
A. Signs of fluid overload: Fluid overload presents with edema, crackles in lungs, and increased blood pressure, not dry skin and mucous membranes.
B. Symptoms: Symptoms are subjective (e.g., pain, nausea), while the given findings are observable signs.
C. Data clustering: The nurse groups related signs (flushed skin, dry mucous membranes, elevated temperature) to identify a pattern suggesting dehydration or fever.
D. Urinary retention: Urinary retention is associated with bladder distention and reduced urine output, not dry skin and mucous membranes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Ethically can look at a friend's chart to see the diagnosis: Accessing a patient’s chart without a legitimate medical reason violates HIPAA and patient confidentiality laws.
B. Shares information from a chart to protect a friend: Confidentiality applies regardless of personal relationships. Unauthorized sharing of patient information is illegal and unethical.
C. Knows that only the Patient’s Bill of Rights advocates confidentiality: Multiple regulations, including HIPAA, protect patient confidentiality, not just the Patient’s Bill of Rights.
D. Reads charts only for professional reasons: Nurses can only access patient records when directly involved in care. Unnecessary access is a breach of confidentiality.
Correct Answer is B
Explanation
A. As difficult to maintain: This is a subjective statement and not a proper nursing diagnosis.
B. As a risk factor: Bed rest increases the risk of complications such as pressure ulcers, deep vein thrombosis (DVT), and muscle atrophy.
C. As a nursing responsibility: While nurses help manage bed rest, it is not classified as a responsibility but as an intervention.
D. As contributing to the patient's recovery: Although bed rest may be necessary, prolonged immobility can have negative effects, making this statement incomplete.
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