What is the correct term for the nursing action of deciding that a nonverbal patient who just had surgery is in pain and administering an analgesic, based on the observation that the patient moans with position changes, the hands are clenched, and the skin is very sweaty?
Using empathy
Setting priorities
Making inferences
Recognizing inconsistencies
The Correct Answer is C
Choice A reason: This is an incorrect choice because using empathy is not the correct term for the nursing action of deciding that a nonverbal patient who just had surgery is in pain and administering an analgesic, based on the observation that the patient moans with position changes, the hands are clenched, and the skin is very sweaty. Empathy is a communication technique that involves understanding and sharing the feelings of another person. However, it is not the term that describes the cognitive process of drawing conclusions from the available data.
Choice B reason: This is an incorrect choice because setting priorities is not the correct term for the nursing action of deciding that a nonverbal patient who just had surgery is in pain and administering an analgesic, based on the observation that the patient moans with position changes, the hands are clenched, and the skin is very sweaty. Setting priorities is a nursing skill that involves determining the order of importance of the patient's problems and interventions. However, it is not the term that describes the cognitive process of drawing conclusions from the available data.
Choice C reason: This is the correct choice because making inferences is the correct term for the nursing action of deciding that a nonverbal patient who just had surgery is in pain and administering an analgesic, based on the observation that the patient moans with position changes, the hands are clenched, and the skin is very sweaty. Making inferences is a critical thinking skill that involves reaching a logical judgment or assumption based on the available data and evidence. The nurse makes an inference that the patient is in pain based on the patient's nonverbal cues and the fact that the patient just had surgery.
Choice D reason: This is an incorrect choice because recognizing inconsistencies is not the correct term for the nursing action of deciding that a nonverbal patient who just had surgery is in pain and administering an analgesic, based on the observation that the patient moans with position changes, the hands are clenched, and the skin is very sweaty. Recognizing inconsistencies is a critical thinking skill that involves identifying discrepancies or contradictions in the data or information. However, it is not the term that describes the cognitive process of drawing conclusions from the available data.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is A
Explanation
Choice A reason: This is correct. Risk for injury related to smoking near supplemental oxygen is the priority nursing diagnosis for this family. Smoking near supplemental oxygen can cause a fire or an explosion that can injure or kill the patient and the spouse. The nurse should educate the family about the dangers of smoking near oxygen and provide resources to help the spouse quit smoking.
Choice B reason: This is incorrect. Risk-prone health behavior related to inability to quit smoking is a relevant nursing diagnosis for this family, but not the priority. Smoking is a harmful habit that can cause various health problems, such as lung cancer, heart disease, and stroke. The nurse should assess the spouse's readiness to quit smoking and provide support and counseling.
Choice C reason: This is incorrect. Ineffective health maintenance related to continued use of cigarettes is a valid nursing diagnosis for this family, but not the priority. Smoking can impair the health of the patient and the spouse, especially if the patient has a respiratory condition that requires supplemental oxygen. The nurse should monitor the patient's and the spouse's vital signs, oxygen saturation, and respiratory status.
Choice D reason: This is incorrect. Ineffective family therapeutic regimen management related to noncompliance is an appropriate nursing diagnosis for this family, but not the priority. Smoking near supplemental oxygen can indicate that the family is not following the prescribed treatment plan for the patient's condition. The nurse should evaluate the family's understanding of the patient's oxygen therapy and the reasons for noncompliance.
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