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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. A patient who had surgery two days ago and is learning how to change the dressing. This is incorrect because this patient is stable and requires routine education, which is not an immediate priority.

B. A patient who was admitted 30 minutes ago for chest pain. This is correct because chest pain can indicate a life-threatening condition such as myocardial infarction. The nurse should assess this patient immediately, monitoring for signs of cardiac compromise and initiating emergency interventions if necessary.

C. A patient who received pain medication 10 minutes ago. This is incorrect because this patient is already receiving treatment, and there is no indication of urgent distress requiring immediate intervention.

D. A patient who is being transferred to a long-term care facility this afternoon. This is incorrect because transfer preparation is not an urgent priority compared to an unstable or potentially critical patient.

A. Risk for alteration in skin integrity B. Activity Intolerance C. Risk for Infection D. Deficient Fluid volume

Correct Answer is B

Explanation

A. While long-term immobility increases the risk of skin breakdown, this is not the primary concern in this scenario.

B. The patient exhibits fatigue, increased heart rate, and orthostatic hypotension, indicating reduced ability to tolerate physical activity, making Activity Intolerance the most appropriate diagnosis.

C. While ICU patients may be at risk for infection, there is no evidence of active infection in this scenario.

D. Orthostatic hypotension can be linked to dehydration, but the case does not provide enough information to confirm a fluid volume deficit.

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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

Explanation

Correct Answer is B

Explanation

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