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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.
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Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics?
- A. risk nursing diagnosis
- B. actual nursing diagnosis
- C. possible nursing diagnosis
- D. wellness diagnosis
Correct Answer: B
Rationale: An actual nursing diagnosis is validated by the presence of major defining characteristics observed in the patient.
Which of the following are examples of nursing responsibilities? Select all that apply.
- A. recognizing the signs and symptoms of pancreatitis when it presents in a patient
- B. making a diagnosis of uterine cancer following diagnostic testing
- C. referring a patient diagnosed with lung cancer to a smoke-cessation group
- D. researching and prescribing medication for an adolescent with uncontrolled asthma
- E. performing range-of-motion exercises on an elderly patient who is in a wheelchair
- F. teaching a group of high school students about the dangers of having unprotected sex
Correct Answer: A,C,E,F
Rationale: Nursing responsibilities include recognizing symptoms, referring patients, performing exercises, and educating, but not diagnosing cancer or prescribing medications, which are medical roles.
Successful implementation of each step of the nursing process requires high-level skills in critical thinking. Which of the following statements accurately describe a guideline for using this process?
- A. Trust clinical judgment and experience over asking for help.
- B. Respect clinical intuition, but never allow it to determine a diagnosis.
- C. Recognize personal biases as a strength in formulating diagnoses.
- D. Keep an open mind and trust your intuition when formulating diagnoses.
Correct Answer: D
Rationale: Keeping an open mind and trusting intuition, while validating with data, supports effective critical thinking in the nursing process.
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 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.