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A nurse is reviewing the health history and physical assessment findings for a patient who is having respiratory problems. Of the following data collected, what data from the health history would be a cue to a nursing diagnosis for this problem?
- A. I often have diarrhea after I eat spicy foods.
- B. My skin is so dry I just cant keep from scratching.
- C. I get out of breath when I walk a few steps.
- D. I just feel so bad about myself these days.
Correct Answer: C
Rationale: Shortness of breath is a direct cue to a respiratory-related nursing diagnosis, as it indicates impaired respiratory function.
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Which of the following statements accurately describe the legal responsibility of the nurse making a diagnosis for a patient?
- A. The nurse may make a diagnosis, but the physician is responsible for making sure it is appropriate for the patient.
- B. The nurse practitioner is responsible for making all nursing diagnoses and determining if they are appropriate for the patient.
- C. The nurse must decide if he or she is qualified to make a nursing diagnosis and will accept responsibility for treating it.
- D. The healthcare facility directs the nursing diagnosis in order to receive payment for services performed.
Correct Answer: C
Rationale: Nurses are legally responsible for ensuring they are qualified to make a nursing diagnosis and for the treatment that follows, as it falls within their scope of practice.
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.
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.
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.
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.