The major difference between the nursing diagnoses "inadequate nutritional intake related to vomiting as manifested by 3-pound weight loss" and "risk for impaired skin integrity related to inadequate nutrition" is that the second diagnosis:
Reflects a problem that does not yet exist.
Needs no defined nursing interventions.
Will not need to be evaluated.
Needs medical intervention.
The Correct Answer is A
Choice A rationale
A risk nursing diagnosis, such as "risk for impaired skin integrity related to inadequate nutrition," identifies a potential problem that does not currently exist but has a high probability of developing if no preventative nursing interventions are implemented. It focuses on the patient's vulnerability to a specific health problem.
Choice B rationale
All nursing diagnoses, including risk diagnoses, require the development of specific nursing interventions aimed at preventing the potential problem from occurring or minimizing its impact. These interventions are crucial for addressing the identified risk factors and promoting patient well-being.
Choice C rationale
Evaluation is a critical component of the nursing process for all nursing diagnoses. The effectiveness of the nursing interventions implemented for a risk diagnosis must be evaluated to determine if they successfully prevented the problem from developing. This ongoing assessment ensures the plan of care is appropriate and achieving the desired outcomes.
Choice D rationale
Nursing diagnoses, including risk diagnoses, are within the scope of nursing practice and guide independent nursing interventions. While collaboration with the medical team is essential for overall patient care, risk diagnoses do not inherently necessitate medical intervention as the primary focus is on preventative nursing actions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
"Patient will ambulate for 15 minutes after lunch" is a planned nursing intervention or goal, outlining a future action for the patient. It describes what is expected to happen, not what has already been implemented and documented.
Choice B rationale
"Patient selected low-sugar snacks independently" describes an observation of the patient's behavior and adherence to a dietary plan. While it reflects an action, it doesn't explicitly document a direct nursing intervention performed.
Choice C rationale
"Patient was medicated with Tylenol 500 mg PO for pain" clearly documents the implementation of a specific nursing intervention – the administration of medication. It states what was done, including the drug, dosage, route, and reason.
Choice D rationale
"Patient participated in group therapy session without prompting" describes the patient's participation in a therapeutic activity. While nurses may facilitate or encourage participation, this statement focuses on the patient's action rather than a direct nursing intervention performed on the patient. .
Correct Answer is A
Explanation
Choice A rationale
"The patient has a fractured right tibia with a cast that was applied 2 days ago" provides the Background, giving relevant history about the patient's current condition. "The nurse requests that the primary health provider examine the patient" is the Recommendation, suggesting a course of action based on the assessment. "The patient reported his pain as a 7 on a 0-10 pain scale 1 hour after he received Norco 10mg PO" describes the Situation, highlighting the current problem or change in condition. "The patient's toes are cool and pale, and the patient reports that the foot feels numb" is the Assessment, presenting the nurse's findings and interpretation of the patient's status.
Choice B rationale
This option incorrectly assigns the documentation entries to the SBAR components. The fractured tibia and cast history are background, not the immediate situation. The pain report after medication is the situation, not background. The recommendation is correctly identified, but the cool, pale, numb toes are the assessment, not the recommendation.
Choice C rationale
This option misidentifies the components. The cool, pale, numb toes are assessment findings, not the situation. The pain report after medication is the situation, not background. The fractured tibia and cast history are background, not the assessment. The request for provider examination is the recommendation.
Choice D rationale
This option incorrectly orders the SBAR components. The request for provider examination is the recommendation, not the situation. The cool, pale, numb toes are the assessment, not the background. The pain report after medication is the situation. The fractured tibia and cast history are background. .
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