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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.
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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.
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 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 student is reviewing a patients chart before giving care. She notes the following diagnoses in the contents of the chart: appendicitis and acute pain. Which of the diagnoses is a medical diagnosis?
- A. neither appendicitis nor acute pain
- B. both appendicitis and acute pain
- C. appendicitis
- D. acute pain
Correct Answer: C
Rationale: Appendicitis is a medical diagnosis made by a physician, while acute pain is a nursing diagnosis based on patient symptoms.
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.