The nurse is caring for a patient with sepsis. The nurse includes potential complication: septic shock in the plan of care. Why is this nursing diagnosis considered to be a collaborative problem?

The patient has a history of noncompliance with prescribed therapeutic regimens.

The patient must be closely monitored in an intensive care unit.

Prevention of septic shock is not a measurable patient outcome.

Both nursing and physician-prescribed interventions are required.

Answer and Explanation

The Correct Answer is D

Choice A reason: This is an incorrect choice because the patient has a history of noncompliance with prescribed therapeutic regimens is not a reason why this nursing diagnosis is considered to be a collaborative problem. A collaborative problem is a potential or actual health problem that requires the intervention of multiple health care professionals from different disciplines to achieve optimal patient outcomes. The patient's history of noncompliance is not related to the nature of the problem or the type of intervention required.

Choice B reason: This is an incorrect choice because the patient must be closely monitored in an intensive care unit is not a reason why this nursing diagnosis is considered to be a collaborative problem. A collaborative problem is a potential or actual health problem that requires the intervention of multiple health care professionals from different disciplines to achieve optimal patient outcomes. The patient's need for close monitoring is not related to the nature of the problem or the type of intervention required.

Choice C reason: This is an incorrect choice because prevention of septic shock is not a measurable patient outcome is not a reason why this nursing diagnosis is considered to be a collaborative problem. A collaborative problem is a potential or actual health problem that requires the intervention of multiple health care professionals from different disciplines to achieve optimal patient outcomes. The measurability of the patient outcome is not related to the nature of the problem or the type of intervention required.

Choice D reason: This is the correct choice because both nursing and physician-prescribed interventions are required is a reason why this nursing diagnosis is considered to be a collaborative problem. A collaborative problem is a potential or actual health problem that requires the intervention of multiple health care professionals from different disciplines to achieve optimal patient outcomes. The problem of septic shock is a complex and life-threatening condition that involves multiple organ systems and requires both medical and nursing interventions to prevent, treat, and monitor the patient's status.

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Correct Answer is B

Explanation

Choice A reason: This is an incorrect choice because exposure-related accident is not the type of error when the wrong type of medication is administered to the patient. Exposure-related accident is an incident that occurs when a person is exposed to a harmful substance or environment, such as radiation, chemicals, or extreme temperatures.

Choice B reason: This is the correct choice because procedure-related accident is the type of error when the wrong type of medication is administered to the patient. Procedure-related accident is an incident that occurs when a person is harmed by a medical or surgical procedure, such as a wrong-site surgery, a medication error, or a catheter infection.

Choice C reason: This is an incorrect choice because organization-related accident is not the type of error when the wrong type of medication is administered to the patient. Organization-related accident is an incident that occurs due to a failure of the system or the management of an organization, such as a lack of communication, a poor policy, or a staffing shortage.

Choice D reason: This is an incorrect choice because equipment-related accident is not the type of error when the wrong type of medication is administered to the patient. Equipment-related accident is an incident that occurs due to a malfunction or misuse of a device or a machine, such as a ventilator, a defibrillator, or a syringe.

A. Powerlessness related to inability to keep from eating during sleep B. Wandering related to cognitive impairment from sleeping aid C. Risk for falls related to ambulating to kitchen while asleep D. Risk for imbalanced nutrition: more than body requirements related to sleep eating

Correct Answer is C

Explanation

Choice A reason: This is an incorrect choice because powerlessness related to inability to keep from eating during sleep is not the highest priority nursing diagnosis for a patient who developed sleep-related eating disorder when taking Zolpidem. Powerlessness is a psychosocial problem that affects the patient's sense of control and self-efficacy. However, it is not the most urgent or life-threatening problem for the patient, as it does not pose an immediate risk of harm or injury.

Choice B reason: This is an incorrect choice because wandering related to cognitive impairment from sleeping aid is not the highest priority nursing diagnosis for a patient who developed sleep-related eating disorder when taking Zolpidem. Wandering is a behavioral problem that involves moving about aimlessly or without purpose. However, it is not the most urgent or life-threatening problem for the patient, as it does not necessarily imply a risk of harm or injury.

Choice C reason: This is the correct choice because risk for falls related to ambulating to kitchen while asleep is the highest priority nursing diagnosis for a patient who developed sleep-related eating disorder when taking Zolpidem. Risk for falls is a safety problem that involves an increased likelihood of falling due to factors such as impaired balance, coordination, or judgment. This is the most urgent and life-threatening problem for the patient, as it can result in serious injuries or complications.

Choice D reason: This is an incorrect choice because risk for imbalanced nutrition: more than body requirements related to sleep eating is not the highest priority nursing diagnosis for a patient who developed sleep-related eating disorder when taking Zolpidem. Risk for imbalanced nutrition: more than body requirements is a physiological problem that involves an intake of nutrients that exceeds metabolic needs. However, it is not the most urgent or life-threatening problem for the patient, as it does not cause an immediate risk of harm or injury.

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The nurse is caring for a patient with sepsis. The nurse includes potential complication: septic shock in the plan of care. Why is this nursing diagnosis considered to be a collaborative problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which type of error is it when the wrong type of medication is administered to the patient?

Correct Answer is B

Explanation

Which is the highest priority nursing diagnosis for a patient who developed sleep-related eating disorder when taking Zolpidem?

Correct Answer is C

Explanation

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

Which is the first action of the nurse when starting care for the patient at the beginning of the shift?

Which term will the nurse use to document the patient’s age-related hearing loss?

Which step of the nursing process is being performed by the nurse who carefully enters a new patient’s medical history and current medication list into the agency’s electronic health record (EHR)?

Which assessment findings put the patient at high risk for development of vision problems? (Select all that apply)

Once a week, staff members from all the disciplines caring for the trauma patients get together to discuss their progress. Which term best describes this patient care action?

Which patient’s needs must be addressed first by the registered nurse?

Which assessment finding indicates to the nurse why the patient is having difficulty sleeping at night?