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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 D

Explanation

A. This patient is newly admitted and potentially unstable, requiring nursing assessment before delegation.

B. Active bleeding indicates a complication requiring nursing intervention, making this patient inappropriate for delegation.

C. A patient with pneumonia on oxygen requires close monitoring of their respiratory status, which falls under nursing responsibilities.

D. This patient is stable and only needs assistance, making them appropriate for NAP delegation.

A. Skip a meal break to catch up on charting. B. Offer to complete another nurse's task. C. Plan time for disruptions. D. Complete the easiest tasks first.

Correct Answer is C

Explanation

A. Skipping breaks can lead to burnout.

B. Taking on another nurse’s task may cause delays in primary responsibilities.

C. Planning for interruptions improves efficiency and prioritization.

D. Completing the easiest tasks first may not be the most efficient approach.

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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 D

Explanation

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Correct Answer is C

Explanation

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