Which of the following is an example of a nursing diagnosis?
Skin breakdown
Elevated blood pressure
Anxiety
Ineffective breathing pattern
The Correct Answer is D
A. Skin breakdown: This is a medical problem or symptom, but it is not a structured nursing diagnosis.
B. Elevated blood pressure: This is a clinical finding rather than a nursing diagnosis.
C. Anxiety: While anxiety is a medical condition, a complete nursing diagnosis should describe the specific effects on the patient, such as "Anxiety related to hospitalization as evidenced by restlessness and increased heart rate."
D. Ineffective breathing pattern: This is a standardized nursing diagnosis as defined by NANDA (North American Nursing Diagnosis Association). It refers to altered respiratory function that nurses can assess and manage.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Severe feelings of restlessness. This describes akathisia, a different extrapyramidal side effect of antipsychotics.
B. Permanent involuntary movements of the face, tongue, and extremities. Tardive dyskinesia is characterized by repetitive, involuntary movements, often affecting the mouth, face, and limbs, and is a long-term side effect of antipsychotic medications.
C. Muscle rigidity and spasms. This describes dystonia, another extrapyramidal symptom, but not tardive dyskinesia.
D. Symptoms that resemble Parkinson's disease. This describes drug-induced parkinsonism, which involves tremors, bradykinesia, and rigidity, not the repetitive movements seen in tardive dyskinesia.
Correct Answer is B
Explanation
A. Headache: While headaches can occur, they are not the most concerning side effect of stimulant medications.
B. Tachycardia: Stimulant medications, such as those used to treat ADHD (e.g., methylphenidate, amphetamines), increase central nervous system activity, which can lead to an increased heart rate (tachycardia).
C. Dizziness: While dizziness can occur, it is not the primary concern with stimulants.
D. Dry mouth: Dry mouth is a possible side effect but is not as clinically significant as tachycardia when monitoring for adverse effects.
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