Nokea
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.
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After completing assessments, a nurse uses the data collected to identify appropriate nursing diagnoses for a patient. What are the nursing diagnoses used for?
- A. selecting nursing interventions to meet expected outcomes
- B. establishing a database of information for future comparison
- C. mutually establishing desired outcomes of the plan of care
- D. evaluating the effectiveness of the established plan of care
Correct Answer: A
Rationale: Nursing diagnoses guide the selection of interventions to achieve expected outcomes, as they provide a framework for addressing patient needs.
A nurse caring for an elderly patient in a long-term care facility notices that the bedding is wet when the patient gets up in the morning. The nurse collects more data to form a conclusion. What type of problem is involved in this scenario?
- A. no problem
- B. possible problem
- C. actual problem
- D. clinical problem
Correct Answer: B
Rationale: Wet bedding suggests a possible problem, such as incontinence, but further data collection is needed to confirm.
A nurse is formulating a nursing diagnosis for a patient with a respiratory disease. Which of the following would be correct?
- A. needs nasal oxygen to improve breathing
- B. cough related to ineffective airway clearance
- C. ineffective airway clearance related to thick mucus
- D. refuses to cough and expectorate thick mucus
Correct Answer: C
Rationale: A correct nursing diagnosis includes the problem, etiology, and evidence, such as 'ineffective airway clearance related to thick mucus.'
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.