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The nurse manager notices that a staff nurse writes a nursing diagnosis as "Impaired Physical Mobility, related to laziness and not having appropriate shoes." Which issue related to the nursing diagnosis will the nurse manager discuss with the staff nurse?

As written, the diagnosis is too complex.

The staff nurse is being judgmental.

The diagnosis is legally questionable.

There is deficiency of supportive data.

Answer and Explanation

The Correct Answer is B

A. The diagnosis is not necessarily complex.

B. Nursing diagnoses should be objective and free from judgment. "Laziness" is subjective and inappropriate.

C. No legal issue is present, but professionalism is lacking.

D. The issue is more about the judgmental phrasing than missing data.

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Correct Answer is D

Explanation

A. Forcing eye contact may be culturally insensitive.

B. No psychological evaluation is warranted based solely on this behavior.

C. Assuming depression without further assessment is inappropriate.

D. In some Asian cultures, avoiding eye contact can be a sign of respect rather than an indicator of depression or psychological distress.

A. Risk B. Actual C. Syndrome D. Wellness

Correct Answer is B

Explanation

A. A risk diagnosis applies when a problem has not yet occurred but is likely. This patient is already experiencing chest pain and hemodynamic instability, requiring an actual diagnosis.

B. The patient has current symptoms of chest pain, sweating, pallor, hypotension, and an irregular pulse, indicating a medical condition (possibly myocardial infarction). This justifies an actual diagnosis.

C. Syndrome diagnoses involve a cluster of related diagnoses, such as frail elderly syndrome. This patient’s case does not meet that definition.

D. Wellness diagnoses focus on improving health, not addressing an active medical crisis.

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The nurse manager notices that a staff nurse writes a nursing diagnosis as "Impaired Physical Mobility, related to laziness and not having appropriate shoes." Which issue related to the nursing diagnosis will the nurse manager discuss with the staff nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?

Correct Answer is D

Explanation

A nurse assesses a patient who reports chest pain radiating down their arm. The nurse notes the patient is sweating and pale, BP 90/50 mmHg, pulse 120bpm, irregular. When developing the plan of care, what type of nursing diagnosis should the nurse use?

Correct Answer is B

Explanation

When using the PIE format for documentation, which of the following elements should the nurse include under 'P?

The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?

A nurse reviews a patient's health record and finds the following data. Which example includes only subjective data?

The nurse is providing care to a client admitted with pressure injuries. The nurse develops a plan of care focusing on healing measures and prevention of further injury. Which task does the nurse delegate to the nursing assistive personnel (NAP)?

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The nurse begins discharge planning for an older adult with left-side weakness. Which action is most important in ensuring that the discharge plan is successful?

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