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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Providing additional written instructions is a helpful teaching strategy but does not directly demonstrate the patient's ability to self-administer the injection correctly. It addresses the teaching method, not the outcome of the teaching.

Choice B rationale

The patient denying concerns does not necessarily indicate successful learning. The patient might have unexpressed concerns or may not fully understand the procedure despite verbalizing otherwise. This statement reflects the patient's verbalization, not their demonstrated skill.

Choice C rationale

The patient correctly self-administering their next scheduled dose of insulin is the most direct and reliable evidence that the teaching was successful. It demonstrates that the patient has acquired the necessary knowledge and skills to perform the injection safely and accurately in a real-life situation.

Choice D rationale

Identifying the steps and equipment used indicates that the patient has some understanding of the procedure. However, it does not guarantee that they can perform the injection correctly. Practical demonstration is required to confirm successful learning of a psychomotor skill.

A. Orientation. B. Termination. C. Working. D. Pre-interaction. E. Evaluation.

Correct Answer is C

Explanation

Choice A rationale

The orientation phase of the interview typically involves introducing oneself, explaining the purpose of the interview, and establishing rapport with the patient. Asking about the drug list occurs after this initial introduction.

Choice B rationale

The termination phase is the concluding part of the interview, where the nurse summarizes key information and discusses the plan of care. Medication history is gathered much earlier in the assessment.

Choice C rationale

The working phase is where the nurse actively collects data about the patient's health history, current condition, medications, and other relevant information. Asking about the drug list, including herbal supplements and over-the-counter medications, is a key component of this data gathering process.

Choice D rationale

The pre-interaction phase occurs before meeting the patient and involves the nurse reviewing available information such as the patient's chart. The actual questioning of the patient happens later.

Choice E rationale

The evaluation phase occurs after interventions have been implemented to assess their effectiveness. It is not the phase where the initial assessment and data collection, including medication history, take place. .

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has just completed teaching the patient how to self-administer insulin injections.Which entry in the patient’s chart demonstrates that the teaching was successful?

Correct Answer is C

Explanation

The nurse completes the assessment for a patient who has just been admitted to the hospital.The nurse carefully documents the patient's current drug list and asks about the use of any herbal supplements or over-the-counter medications.Which phase of the interview does this occur in?

Correct Answer is C

Explanation

With whom should a nurse share her password for access to the facility's computer system?

The nursing process is best defined as a framework for the organization of individualized nursing care.

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The nurse is assessing a patient with chest pain who has just come to the hospital. Which open-ended query will provide the nurse with helpful information about the patient's health status?

The nurse is caring for a patient who came to the hospital with acute shortness of breath.What is the priority action of the nurse as the assessment process is started?

A nurse's sibling had a diagnostic test at the nurse's facility.The sibling asks the nurse to look up the result in the computer.The nurse should identify which of the following as the reason for her decision about her sibling's request?

The patient has a goal of maintaining urinary output of at least 80 mL/hour as part of the nursing care plan.However, the patient's urinary output for the shift was only 20 mL/hour.What is the appropriate action of the nurse?

The nurse is caring for a nonverbal client who is moaning with position changes, the hands and teeth are clenched, and the skin is very diaphoretic.The nurse interprets this as the client is experiencing pain and decides to administer an analgesic.What is the correct term for this nursing action?