Which action by the nurse demonstrates the concept of nurse autonomy?

The nurse braids the patient’s long hair to prevent tangles.

The nurse checks the policy manual before changing the central line dressing.

The nurse counts the patient’s pulse before administering digoxin.

The nurse directs the nursing assistant to obtain the patient's weight.

Answer and Explanation

The Correct Answer is B

Choice A reason: This is an incorrect choice because the nurse braids the patient’s long hair to prevent tangles is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Braiding the patient’s hair is a personal care task that does not require the nurse to use their own judgment or expertise.

Choice B reason: This is the correct choice because the nurse checks the policy manual before changing the central line dressing is an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Checking the policy manual before changing the central line dressing shows that the nurse is responsible for following the evidence-based guidelines and standards of practice for this procedure.

Choice C reason: This is an incorrect choice because the nurse counts the patient’s pulse before administering digoxin is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Counting the patient’s pulse before administering digoxin is a routine task that is prescribed by the physician and does not involve the nurse’s own decision making.

Choice D reason: This is an incorrect choice because the nurse directs the nursing assistant to obtain the patient's weight is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Directing the nursing assistant to obtain the patient's weight is a task that is delegated by the nurse and does not reflect the nurse’s own authority or initiative.

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Correct Answer is B

Explanation

Choice A reason: This is an incorrect choice because temperature, pulse, and blood pressure are not the most important vital signs for a patient who is experiencing shortness of breath. Temperature is not directly related to respiratory function, and pulse and blood pressure can be affected by other factors, such as anxiety or medication.

Choice B reason: This is the correct choice because pulse, respirations, and oxygen saturation are the most important vital signs for a patient who is experiencing shortness of breath. Pulse reflects the heart rate and rhythm, which can be altered by respiratory distress. Respirations reflect the rate and depth of breathing, which can indicate the severity of the condition. Oxygen saturation reflects the percentage of hemoglobin that is bound with oxygen, which can indicate the adequacy of oxygenation.

Choice C reason: This is an incorrect choice because temperature, pulse, and respirations are not the most important vital signs for a patient who is experiencing shortness of breath. Temperature is not directly related to respiratory function, and respirations alone do not provide enough information about the oxygenation status of the patient.

Choice D reason: This is an incorrect choice because respirations, blood pressure, and pain are not the most important vital signs for a patient who is experiencing shortness of breath. Blood pressure can be affected by other factors, such as anxiety or medication, and pain is a subjective symptom that can vary from person to person. Oxygen saturation is a more objective and reliable indicator of oxygenation than pain.

A. Perceived constipation related to expectation of daily bowel movements. B. Impaired bowel elimination related to abdominal muscle weakness. C. Risk for constipation related to irregular defecation habits. D. Constipation related to side effects of pain medication.

Correct Answer is D

Explanation

Choice A reason: This is an incorrect choice because perceived constipation related to expectation of daily bowel movements is not an appropriate nursing diagnosis for this patient. Perceived constipation is a subjective problem that occurs when the patient's bowel elimination pattern does not meet their personal expectations. The patient may not have any objective signs of constipation, such as hard stools, straining, or abdominal discomfort. This diagnosis is not applicable to this patient, who has objective signs of constipation and a clear cause of the problem.

Choice B reason: This is an incorrect choice because impaired bowel elimination related to abdominal muscle weakness is not an appropriate nursing diagnosis for this patient. Impaired bowel elimination is a problem that occurs when the patient has difficulty in passing stools or has a change in bowel habits. Abdominal muscle weakness is a possible factor that can affect bowel function, but it is not the cause of the problem for this patient. This diagnosis is not applicable to this patient, who has a normal muscle strength and a clear cause of the problem.

Choice C reason: This is an incorrect choice because risk for constipation related to irregular defecation habits is not an appropriate nursing diagnosis for this patient. Risk for constipation is a potential problem that occurs when the patient is vulnerable to developing constipation due to various factors. Irregular defecation habits are a possible factor that can increase the risk of constipation, but they are not the cause of the problem for this patient. This diagnosis is not applicable to this patient, who already has constipation and a clear cause of the problem.

Choice D reason: This is the correct choice because constipation related to side effects of pain medication is an appropriate nursing diagnosis for this patient. Constipation is a problem that occurs when the patient has infrequent, difficult, or incomplete bowel movements. Pain medication, especially opioids, are a common cause of constipation, as they can slow down the gastrointestinal motility and reduce the stool volume and water content. This diagnosis is applicable to this patient, who has objective signs of constipation and a clear cause of the problem..

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Which action by the nurse demonstrates the concept of nurse autonomy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which vital signs are most important for a patient who is experiencing shortness of breath?

Correct Answer is B

Explanation

The nurse is caring for a patient who has been unable to have a bowel movement for the last 4 days after taking prescribed narcotic pain medication. Which nursing diagnosis is appropriate for this patient?

Correct Answer is D

Explanation

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