Try Naxlex NCLEX-RN (Free-Trial)

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."

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

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.

A. Planning B. Assessment C. Implementation D. Evaluation

Correct Answer is B

Explanation

A. Planning. This is incorrect because the planning phase involves setting goals and determining interventions based on the assessment data. Allergy information should be collected before this phase.

B. Assessment. This is correct because the assessment phase involves gathering subjective and objective data about the patient. Asking about allergies is part of the initial health history to ensure safe care planning.

C. Implementation. This is incorrect because the implementation phase involves carrying out interventions based on the data collected in the assessment. Checking allergies before giving medications or treatments should occur earlier.

D. Evaluation. This is incorrect because evaluation involves determining the effectiveness of interventions. Allergy assessment should be completed long before this phase to prevent potential reactions.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse formulates several nursing diagnoses then prioritizes using Maslow's hierarchy. What nursing diagnosis should have the highest priority?

Correct Answer is A

Explanation

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

Correct Answer is B

Explanation

A nurse assesses a patient who reports chest pain radiating down their arm. The nurse notes the patient is sweating and pale, BP 90/50 mmHg, pulse 120bpm, irregular. When developing the plan of care, what type of nursing diagnosis should the nurse use?

When using the PIE format for documentation, which of the following elements should the nurse include under 'P?

A nurse is discussing time management strategies with another nurse. The nurse should include which of the following as an example of a time management strategy?

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?

After receiving change of shift report, the nurse delegates hygiene care for the caseload of patients. Which patient should the nurse delegate to the nursing assistive personnel (NAP)?

A nurse administers the prescribed inhaled medication then auscultates the patient's lungs after the medication has finished. In what phase of the nursing process would the nurse's action of auscultating the lungs occur?

The nurse is providing care to a patient in an acute care facility. Which of the following are examples of independent nursing interventions? (Select All that Apply.)