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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.
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A student identifies Fatigue as a health problem and nursing diagnosis for a patient receiving home care for treatment of metastatic cancer. What statement or question would be best to validate this patient problem?
- A. I have assessed you and find you are fatigued.
- B. I analyzed and interpreted your information as fatigue.
- C. Why are you so tired all the time?
- D. I think fatigue is a problem for you; do you agree?
Correct Answer: D
Rationale: Asking the patient to confirm fatigue validates the diagnosis collaboratively with the patient.
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.
In addition to identifying responses to actual or potential health problems, what is another purpose of the diagnosing step in the nursing process?
- A. to collect information about subjective and objective data
- B. to correlate nursing and medical diagnostic criteria
- C. to identify etiologies of health problems
- D. to evaluate mutually developed expected outcomes
Correct Answer: C
Rationale: Identifying etiologies of health problems is a key purpose of the diagnosing step, as it helps determine the underlying causes of a patient's health issues, guiding appropriate interventions.
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.