Nokea
A nurse completes a health history and physical assessment for an adolescent before he begins football practice. Based on findings, the nurse recommends reinforcing health habits. What conclusion did the nurse reach after interpreting and analyzing the data?
- A. no problem
- B. possible problem
- C. actual problem
- D. clinical problem
Correct Answer: A
Rationale: Recommending reinforcement of health habits suggests no immediate problem was identified, indicating a 'no problem' conclusion.
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A nurse writes the following nursing diagnosis for a patient with Alzheimers: Disturbed Thought Processes related to Alzheimers disease as evidenced by incoherent language. Which part of this diagnosis is considered the problem statement?
- A. disturbed thought processes
- B. related to
- C. Alzheimers disease
- D. incoherent language
Correct Answer: A
Rationale: The problem statement in a nursing diagnosis is the identified health issue, which is 'disturbed thought processes' in this case.
The nurse takes a patients vital signs and finds the pulse rate to be 120 beats/min. What would the nurse do next to interpret and analyze this pulse rate?
- A. Compare the patients pulse rate to the standard range.
- B. Notify the patients healthcare provider.
- C. Document the pulse in the appropriate chart page.
- D. Ask another nurse to verify the pulse rate.
Correct Answer: A
Rationale: Comparing the pulse rate to the standard range is the next step to determine if it is abnormal and requires further action.
A nursing diagnosis is written as Disturbed Self-Esteem related to presence of large scar over left side of face. What does the phrase Disturbed Self-Esteem identify?
- A. the expected outcome of the plan of care
- B. a cue to determining a health problem
- C. the major defining characteristic of a health problem
- D. the health state or problem of the patient
Correct Answer: D
Rationale: Disturbed Self-Esteem' identifies the patient's health state or problem in the nursing diagnosis.
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.
A nurse is formulating a diagnosis for a patient who is reliving a brutal mugging that took place several months ago. The patient is crying uncontrollably and states that he cant live with this fear. Which of the following diagnoses for this patient is correctly written?
- A. post-trauma syndrome related to being attacked
- B. psychological overreaction related to being attacked
- C. needs assistance coping with attack
- D. mental distress related to being attacked
Correct Answer: A
Rationale: Post-trauma syndrome related to being attacked' is a correctly formatted nursing diagnosis, identifying the problem and its cause.