Identify the defining characteristic in the following nursing diagnosis statement: Altered speech related to recent neurological disturbance as evidenced by inability to speak in complete sentences:
"Inability to speak in complete sentences"
"Recent neurological disturbance"
"Altered speech"
"As evidenced by"
The Correct Answer is A
A. "Inability to speak in complete sentences": In a nursing diagnosis, the defining characteristic is the observable or measurable cue that demonstrates the existence of the problem. The inability to speak in complete sentences is the evidence that the client exhibits altered speech, providing a concrete manifestation of the diagnosis.
B. "Recent neurological disturbance": This phrase represents the related factor or etiology in the nursing diagnosis, explaining the probable cause of the altered speech. While it helps link the problem to its source, it is not a defining characteristic because it is not an observable symptom or behavior.
C. "Altered speech": This is the actual nursing diagnosis or problem statement, not the defining characteristic. It identifies the health issue requiring nursing intervention but does not specify how the problem presents in the client.
D. "As evidenced by": This phrase functions as a connector between the problem and the defining characteristic. It signals that the following statement will describe the observable manifestation but is not itself a defining characteristic.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E"]
Explanation
A. Temperature 101° F: This is objective data because it is measurable using a thermometer. It provides quantifiable evidence of the patient’s condition rather than relying on the patient’s personal perception or report.
B. Moist skin: Moisture of the skin is observable and measurable by the nurse through inspection and palpation, making it objective data. It reflects a physiologic finding rather than the patient’s description.
C. Heart rate 90: Heart rate is determined using a stethoscope, monitor, or palpation and is a numerical, quantifiable measurement. This makes it objective data rather than information reported by the patient.
D. Pain 3/10: Pain rating is subjective data because it is based on the patient’s personal perception and experience. Pain cannot be measured directly by the nurse and relies entirely on the patient’s self-report.
E. Nausea: Nausea is also subjective data because it is a symptom experienced internally by the patient. The nurse cannot observe or measure it directly; it must be reported by the patient to be documented.
Correct Answer is D
Explanation
A. Client who urinates frequently due to diuretic therapy: Increased urination may lead to fluid loss and potential dehydration if not managed, which can affect skin turgor and perfusion. However, with adequate fluid replacement, this factor alone does not significantly impair the physiological processes required for wound healing.
B. Client with limited mobility recovering from knee surgery: Limited mobility can increase the risk of pressure injuries due to prolonged pressure over bony prominences and reduced circulation. While this may contribute to delayed healing if a wound develops, it does not inherently impair systemic healing processes as chronic metabolic and vascular conditions.
C. Client who is NPO one day before abdominal surgery: Short-term NPO status typically does not result in significant nutritional deficiency or impair wound healing. The body’s nutrient stores and perioperative management generally compensate for this brief period without oral intake, making it a minimal risk factor.
D. Client with diabetes, obesity and current cigarette smoker: Diabetes impairs wound healing through microvascular damage, reduced tissue perfusion, and impaired leukocyte function, increasing infection risk. Obesity decreases vascularity of adipose tissue and places mechanical stress on wounds, while smoking causes vasoconstriction and reduces oxygen delivery due to carbon monoxide exposure. These factors significantly disrupt all phases of wound healing.
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