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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 B

Explanation

A. Skin feeling warm to the touch. This is incorrect because warmth may indicate inflammation, infection, or increased blood flow, but it does not necessarily mean the skin’s integrity is impaired. Skin integrity refers to the structural intactness of the skin.

B. Presence of a wound with partial-thickness skin loss. This is correct because partial-thickness skin loss indicates that the protective barrier of the skin has been compromised. This is a clear sign of impaired skin integrity, which requires appropriate assessment and intervention to promote healing and prevent infection.

C. Dry skin with no visible lesions. This is incorrect because while dry skin may be at risk for breakdown, it does not indicate that the skin is currently impaired. Intact dry skin still maintains its structural integrity.

D. Slight redness of the skin after applying pressure. This is incorrect because transient redness that disappears after pressure relief is not necessarily a sign of skin breakdown. However, if redness persists (non-blanchable erythema), it may indicate a stage 1 pressure injury, which would then suggest potential skin integrity impairment.

A. 42 year old who is due to arrive from the emergency room and has experienced a stroke B. 43 year old female who is post operative surgery and is bleeding from their wound C. 82 year old who was admitted several hours ago with pneumonia, is receiving oxygen and needs a complete bath D. 21 year old who had minor hand surgery 24 hours ago needs an assistance to bathe

Correct Answer is D

Explanation

A. This patient is newly admitted and potentially unstable, requiring nursing assessment before delegation.

B. Active bleeding indicates a complication requiring nursing intervention, making this patient inappropriate for delegation.

C. A patient with pneumonia on oxygen requires close monitoring of their respiratory status, which falls under nursing responsibilities.

D. This patient is stable and only needs assistance, making them appropriate for NAP delegation.

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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

Which of the following signs is most indicative of impaired skin integrity?

Correct Answer is B

Explanation

After receiving change of shift report, the nurse delegates hygiene care for the caseload of patients. Which patient should the nurse delegate to the nursing assistive personnel (NAP)?

Correct Answer is D

Explanation

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 administers the prescribed inhaled medication then auscultates the patient's lungs after the medication has finished. In what phase of the nursing process would the nurse's action of auscultating the lungs occur?

Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient?

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The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?

Which patient scenario of a surgical patient in pain is most indicative of critical thinking?

Which of the following is the most appropriate open-ended question to begin a nursing assessment?

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?