Which nursing diagnosis is written in the correct format when using NANDA-I taxonomy?
Inability to Ingest Food, related to imbalanced nutrition: less than body requirements, as evidenced by inadequate food intake, weight less than 20% under ideal body weight
Caregiver Role Strain, related to depression, as evidenced by constant crying
Impaired Skin Integrity, related to physical immobility, as evidenced by a skin tear over sacral area
Bowel Obstruction, related to recent abdominal surgery, as evidenced by nausea, vomiting, and abdominal pain
The Correct Answer is C
A. Inability to Ingest Food, related to imbalanced nutrition: less than body requirements, as evidenced by inadequate food intake, weight less than 20% under ideal body weight. This is incorrect because "Inability to Ingest Food" is not a NANDA-I approved nursing diagnosis.
B. Caregiver Role Strain, related to depression, as evidenced by constant crying. This is incorrect because "depression" is a medical diagnosis and not an appropriate etiology for a nursing diagnosis. Nursing diagnoses should be based on nursing-related causes.
C. Impaired Skin Integrity, related to physical immobility, as evidenced by a skin tear over sacral area. This is correct because it follows the correct NANDA-I format:
Diagnosis: Impaired Skin Integrity
Etiology (related to): Physical immobility
Defining characteristics (as evidenced by): Skin tear over the sacral area
D. Bowel Obstruction, related to recent abdominal surgery, as evidenced by nausea, vomiting, and abdominal pain. This is incorrect because "Bowel Obstruction" is a medical diagnosis, not a nursing diagnosis. Nursing diagnoses focus on patient responses, such as "Risk for Impaired Bowel Elimination."
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. This is a closed-ended question that leads to a simple "yes" or "no" response, limiting the amount of information the nurse gathers.
B. While this is important information, it is not an appropriate opening question for a full nursing assessment, as it does not encourage the patient to share their primary concern.
C. This open-ended question allows the patient to provide a detailed narrative, helping the nurse gather a comprehensive history.
D. This is a closed-ended question that focuses only on pain rather than encouraging the patient to share their full reason for seeking care.
Correct Answer is C
Explanation
A. Inability to Ingest Food, related to imbalanced nutrition: less than body requirements, as evidenced by inadequate food intake, weight less than 20% under ideal body weight. This is incorrect because "Inability to Ingest Food" is not a NANDA-I approved nursing diagnosis.
B. Caregiver Role Strain, related to depression, as evidenced by constant crying. This is incorrect because "depression" is a medical diagnosis and not an appropriate etiology for a nursing diagnosis. Nursing diagnoses should be based on nursing-related causes.
C. Impaired Skin Integrity, related to physical immobility, as evidenced by a skin tear over sacral area. This is correct because it follows the correct NANDA-I format:
Diagnosis: Impaired Skin Integrity
Etiology (related to): Physical immobility
Defining characteristics (as evidenced by): Skin tear over the sacral area
D. Bowel Obstruction, related to recent abdominal surgery, as evidenced by nausea, vomiting, and abdominal pain. This is incorrect because "Bowel Obstruction" is a medical diagnosis, not a nursing diagnosis. Nursing diagnoses focus on patient responses, such as "Risk for Impaired Bowel Elimination."
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