Which of the following is an example of a nursing diagnosis?

Skin breakdown

Elevated blood pressure

Anxiety

Ineffective breathing pattern

Answer and Explanation

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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Correct Answer is C

Explanation

A. Hypertension: Blood loss leads to hypovolemia, which usually causes hypotension, not hypertension.

B. Hypothermia: While hypothermia can occur postoperatively, it is not the most direct result of blood loss.

C. Tachycardia: Blood loss leads to decreased circulating volume, triggering tachycardia as a compensatory response to maintain oxygen delivery.

D. Bradypnea: Severe blood loss is more likely to cause tachypnea (rapid breathing) rather than slow respirations.

A. Chest physiotherapy (CPT) every 4 hours while awake B. Oxygen therapy via nasal cannula at 3 to 4 L/min C. Add humidification to the oxygen source D. Raise the head of the patient's bed

Correct Answer is A

Explanation

A. Chest physiotherapy (CPT) every 4 hours while awake. CPT is used to mobilize secretions but may be too aggressive for a patient with infiltrates and respiratory distress, as it can increase fatigue and worsen respiratory status.

B. Oxygen therapy via nasal cannula at 3 to 4 L/min. Low-flow oxygen therapy is often used in COPD to prevent hypoxemia while avoiding CO₂ retention.

C. Add humidification to the oxygen source. Humidified oxygen helps prevent airway dryness and improves secretion clearance, which is beneficial for COPD patients.

D. Raise the head of the patient's bed. Elevating the head of the bed promotes lung expansion and improves oxygenation, making this an appropriate intervention.

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Which of the following is an example of a nursing diagnosis?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is A

Explanation

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