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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

Answer and Explanation

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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Correct Answer is B

Explanation

A. Temperature and bowel sounds are measurable, making them objective data rather than subjective.

B. These symptoms cannot be measured or observed by the nurse; they are based on the patient's personal experience, making them subjective data.

C. While the cough is subjective, the respiratory rate is measurable and therefore objective. Since the option includes both types of data, it is not the best answer.

D. White blood cell count is objective. Pain rating is subjective, but since this option includes both types of data, it is not the best choice.

A. Altered Nutrition: Less Than Body Requirements B. Ineffective Coping C. Risk for Falls D. Impaired Mobility

Correct Answer is A

Explanation

A. Maslow’s hierarchy prioritizes physiological needs first, including nutrition, hydration, and oxygenation. This is the most immediate concern.

B. While mental health is important, psychosocial needs are a lower priority than basic physiological needs like nutrition.

C. Fall prevention is essential, but it is a potential problem rather than an existing physiological issue, making it a lower priority than inadequate nutrition.

D. Mobility is important, but ensuring adequate nutrition is more critical to prevent further complications such as muscle wasting and delayed wound healing.

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Which nursing diagnosis is written in the correct format when using NANDA-I taxonomy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is A

Explanation

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