Nokea
A nurse caring for an elderly patient in a long-term care facility notices that the bedding is wet when the patient gets up in the morning. The nurse collects more data to form a conclusion. What type of problem is involved in this scenario?
- A. no problem
- B. possible problem
- C. actual problem
- D. clinical problem
Correct Answer: B
Rationale: Wet bedding suggests a possible problem, such as incontinence, but further data collection is needed to confirm.
You may also like to solve these questions
A nurse develops a plan of care to meet the needs of a patient who has had a large loss of blood after a snowmobile crash. The interventions include administering and monitoring the patients physiologic response to intravenous fluids and blood. What has the nurse focused care on?
- A. a medical diagnosis
- B. a nursing diagnosis
- C. a collaborative problem
- D. a goal for care
Correct Answer: C
Rationale: This scenario describes a collaborative problem, as it involves joint interventions between nursing and medical care, such as administering fluids and blood.
Which of the following patient care concerns is clearly a nursing responsibility?
- A. prescribing medications
- B. monitoring health status changes
- C. ordering diagnostic examinations
- D. performing surgical procedures
Correct Answer: B
Rationale: Monitoring health status changes is a core nursing responsibility, as it involves assessing and tracking patient conditions, unlike prescribing medications or performing surgeries, which are medical responsibilities.
A nurse is formulating a nursing diagnosis for a patient with a respiratory disease. Which of the following would be correct?
- A. needs nasal oxygen to improve breathing
- B. cough related to ineffective airway clearance
- C. ineffective airway clearance related to thick mucus
- D. refuses to cough and expectorate thick mucus
Correct Answer: C
Rationale: A correct nursing diagnosis includes the problem, etiology, and evidence, such as 'ineffective airway clearance related to thick mucus.'
Of all the benefits of using nursing diagnoses, which one is probably the most important to nurses?
- A. defining the domain of nursing practice
- B. informing patients of their care
- C. improving communication among nurses
- D. structuring curricular content
Correct Answer: C
Rationale: Improved communication among nurses is a key benefit, as nursing diagnoses provide a standardized language for care.
What is the focus of a diagnostic statement for a collaborative problem?
- A. the patient problem
- B. the potential complication
- C. the nursing diagnosis
- D. the medical diagnosis
Correct Answer: B
Rationale: Collaborative problems focus on potential complications that require both nursing and medical interventions to manage.