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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The client has a pleasant affect: "Affect" refers to outward emotional expression, whereas "mood" is the client's internal emotional state.
B. The client appears happy with an elevated mood: The nurse should document objective data rather than interpreting the client’s emotions.
C. The client self-isolated today: While self-isolation may indicate mood disturbances, it does not directly document the client’s reported mood.
D. The client rates their mood 4 out of 10: This entry reflects the client’s subjective report using a measurable scale, making it the most accurate documentation.
Correct Answer is D
Explanation
A. Chronic confusion r/t ECT treatment. Memory impairment may occur but is not the immediate priority.
B. Activity intolerance r/t weakness. Weakness can occur but is not the most urgent concern post-ECT.
C. Impaired social interaction r/t confusion. Social interaction is a lower priority compared to physical safety.
D. Risk for injury r/t altered mental status. Post-ECT, clients may be confused or disoriented, increasing their risk of falls or injury. Ensuring safety is the top priority.
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