Which statement is true regarding nursing diagnoses?
North American Nursing Diagnosis Association (NANDA) revises the diagnostic labels every 5 years.
A nursing diagnosis describes a health problem amenable to intervention.
Medical diagnosis is included in the nursing diagnosis.
LPNs/LVNs formulate nursing diagnoses.
The Correct Answer is B
A. North American Nursing Diagnosis Association (NANDA) revises the diagnostic labels every 5 years:
This statement is not accurate. The North American Nursing Diagnosis Association (NANDA) International does review and revise the nursing diagnoses regularly, but it's not on a fixed 5-year schedule. Changes are made based on evolving healthcare practices, new research, and emerging health issues.
B. A nursing diagnosis describes a health problem amenable to intervention:
This statement is true. A nursing diagnosis identifies a specific health problem that can be addressed through nursing interventions. It provides the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable.
C. Medical diagnosis is included in the nursing diagnosis:
This statement is incorrect. Nursing diagnoses are distinct from medical diagnoses. Medical diagnoses identify diseases or pathologies, whereas nursing diagnoses focus on the patient's responses to the health condition. Nursing diagnoses are within the domain of nursing practice and are formulated based on nursing assessments.
D. LPNs/LVNs formulate nursing diagnoses:
This statement is generally true. Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) can formulate nursing diagnoses as part of their scope of practice. However, the complexity of the diagnosis and the depth of assessment often determine the level of nurse involved in formulating nursing diagnoses. Registered Nurses (RNs) typically handle more complex patient cases and nursing diagnoses
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Correct Answer is D
Explanation
A. Use open-ended questions:
Open-ended questions are typically avoided when communicating with aphasic patients. These questions require more complex responses, which might be difficult for someone with language impairments.
B. Not assume that the patient can understand what is heard:
This is a prudent approach. Assuming comprehension without confirmation can lead to misunderstandings. It's better to confirm understanding through non-verbal cues or other communication methods.
C. Talk to the family instead:
While involving family members is important, it doesn't replace direct communication with the patient. The nurse should attempt to communicate directly with the patient, using appropriate techniques.
D. Ask one question at a time:
This is the most suitable option. Asking one question at a time allows the patient to focus on a specific topic and respond more effectively, especially if they have difficulty processing complex information.
Correct Answer is D
Explanation
A. Help the patient understand the objectives of care:
This is a part of the admission process, where the nurse educates the patient about what to expect during their stay, their treatment plan, and the objectives of their care. While important, it's not the primary goal of the admission interview, which is more focused on building rapport and understanding the patient's needs and concerns.
B. Initiate nursing care plan forms:
This task occurs after the admission interview and is based on the information gathered during the interview. Nursing care plans are developed to address the patient's specific needs and concerns, but the initiation of these plans is not the primary goal of the admission interview.
C. Identify the patient's major complaints:
Identifying the patient's concerns and complaints is indeed a part of the admission interview. However, the primary goal of the interview is broader: it's about establishing a connection, ensuring the patient feels heard and understood, and initiating a therapeutic relationship. While identifying complaints is important for addressing immediate concerns, the overall goal is to build trust and rapport.
D. Establish rapport:
Establishing rapport is the fundamental goal of the admission interview. It involves creating a positive and respectful relationship with the patient, which in turn fosters open communication. When rapport is established, patients are more likely to share important information about their health, which is vital for delivering effective and patient-centered care. Building rapport helps in making the patient comfortable, easing anxiety, and creating an environment where the patient feels valued and understood.
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