Which of the following assists the nurse in the identification of nursing diagnoses?

validated data

data clustering

subjective data

objective data

Answer and Explanation

The Correct Answer is B

A. Validated data: While accurate data is crucial, validated data alone does not form a nursing diagnosis.

B. Data clustering: Data clustering involves grouping related signs, symptoms, and risk factors to determine patterns that lead to a nursing diagnosis.

C. Subjective data: Subjective data (e.g., pain, nausea) is part of assessment but must be combined with objective data to establish a diagnosis.

D. Objective data: Objective data (e.g., lab results, physical exam findings) is important, but a nursing diagnosis requires a comprehensive approach, including data clustering.

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Correct Answer is A

Explanation

A. Pain: Pain is the most immediate concern in this scenario. Managing pain is critical for comfort and preventing further complications.

B. Skin integrity: While skin integrity may be a concern (e.g., pressure ulcers if immobile), it is not the most urgent issue at admission.

C. Fluid volume: There is no mention of dehydration or blood loss. Fluid volume is not the primary concern.

D. Knowledge deficit: While patient education is important, managing pain takes priority over knowledge deficits in acute injuries.

A. focused B. body systems C. subjective D. complete

Correct Answer is A

Explanation

A. Focused: A focused assessment is ongoing and directed at specific problems based on the patient’s condition (e.g., assessing pain, circulation, or respiratory status frequently).

B. Body systems: Body systems assessments are structured assessments that evaluate a particular system (e.g., cardiovascular, respiratory) rather than continuous monitoring.

C. Subjective: Subjective assessment includes patient-reported symptoms but does not define the type of continuous assessment nurses perform.

D. Complete: A complete (or comprehensive) assessment is done at admission, not continuously.

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Which of the following assists the nurse in the identification of nursing diagnoses?

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Naxlex Comprehensive Predictor Exams

Your patient is admitted with a serious injury of the left hip after a fall at home. She is crying with severe pain in her left hip and leg. Which nursing diagnosis would apply to this patient's immediate needs?

Correct Answer is A

Explanation

Select the type of assessment which is performed continuously throughout nurse-patient contact:

Correct Answer is A

Explanation

A charge nurse is reviewing documentation with a group of newly hired nurses. Which of the following guidelines should be followed when documenting in a patient record? (select all that apply)

Which of the following assists the nurse in the identification of nursing diagnoses?

Identify the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis:

Patient health care records are:

Who should document care in the patient record?

The primary source of assessment information is:

During the shift, the nurse charts only additional treatments done or withheld, changes in patient condition, and new concerns. Charting these factors demonstrates which of the following type of charting?

Subjective data provided by the patient included complaints of intermittent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as: