The nurse becomes frustrated when a patient insists on taking herbal remedies rather than prescribed medications and spends certain hours of each day in prayer.
The patient also prefers the care of the spiritual healer over the attending physician.
Which factor may be responsible for the nurse's frustration?

Choice B rationale

Reinserting a urinary catheter requires a physician's order as it is an invasive procedure that falls outside the scope of independent nursing practice. Catheterization carries risks of infection and trauma, necessitating medical authorization.

Choice D rationale

Administering a medication, even a mild stool softener, requires a physician's prescription. Nurses cannot independently prescribe or initiate medication therapy. This intervention is based on a medical order to manage or prevent constipation.

Choice A rationale

Calculating fluid intake and output is a routine nursing assessment and monitoring activity that nurses perform independently to evaluate a patient's hydration status and kidney function. It does not require a physician's order.

Choice C rationale

Encouraging fluid and fiber intake are independent nursing interventions aimed at promoting healthy bowel function. Nurses can educate patients and suggest lifestyle modifications without a direct physician's order.

Choice E rationale

Assessing the abdomen for distention, bowel sounds, and tenderness is a physical assessment skill that nurses use independently to gather data about a patient's gastrointestinal system. It is a part of the nursing assessment process.

Choice A rationale

This statement is written as a patient outcome, not a nursing diagnosis. A nursing diagnosis identifies a patient problem based on assessment data. Outcome statements describe the desired change in patient status as a result of nursing interventions and should be specific, measurable, achievable, relevant, and time-bound (SMART).

Choice B rationale

Similar to Choice A, this statement describes a desired patient outcome with specific criteria. While it includes evidence of improvement, it does not identify the underlying nursing diagnosis or the "related to" factor causing the potential nutritional deficit. A nursing diagnosis requires identifying the problem, its cause, and supporting evidence.

Choice C rationale

This statement correctly identifies a nursing diagnosis with three parts: the problem ("Impaired physical mobility"), the etiology or related factor ("related to extreme weakness"), and the supporting evidence ("as evidenced by the inability to perform active ROM exercises, inability to transfer from bed to chair, and use of a walker when ambulating"). This structure is characteristic of an accurate nursing diagnosis.

Choice D rationale

This statement presents an inaccurate and judgmental related factor ("due to the patient being lazy"). Nursing diagnoses should be based on physiological, psychological, sociological, or spiritual responses to health conditions or life processes, not on subjective or potentially stigmatizing attributions. Additionally, the evidence provided describes the skin breakdown but the stated cause is inappropriate and unprofessional.