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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.
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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 nursing diagnoses is an example of a wellness diagnosis?
- A. Acute Pain
- B. Risk for Infection
- C. Readiness for Enhanced Parenting
- D. Possible Chronic Low Self-Esteem
Correct Answer: C
Rationale: A wellness diagnosis, like 'Readiness for Enhanced Parenting,' focuses on promoting higher levels of health or function.
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.
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.
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.