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 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.

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

When assessing a patient taking stimulant medications, the nurse should monitor for which of the following?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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Which entry made my nurse most accurately documents a client's mood?

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Which identifier should the nurse use during the initial time-out to determine the right patient?

Which of the following medications can cause serotonin syndrome?