Nokea
The nurse writes two patient problems: (1) inadequate nutritional intake related to vomiting as manifested by a 3-lb weight loss and (2) risk for impaired skin integrity related to inadequate nutrition. What is the major difference between these diagnoses?
- A. The second diagnosis needs no defined nursing interventions.
- B. The second diagnosis needs medical intervention.
- C. The second diagnosis will not need to be evaluated.
- D. The second diagnosis reflects a problem that does not yet exist.
Correct Answer: D
Rationale: The actual patient problem represents a condition that is currently present. 'Risk for' diagnoses are those that the patient is susceptible to, but not yet troubled by.
You may also like to solve these questions
What objective data should the nurse include after a patient assessment?
- A. Headache of 3 days' duration
- B. Severe stomach cramps
- C. Flatulence
- D. Anxiety
Correct Answer: C
Rationale: Objective data are observable and measurable by people other than the patient.
During an admission assessment the nurse collects objective and subjective data. What is an example of subjective data?
- A. The patient complains of nausea.
- B. The patient is vomiting.
- C. The patient experiences tachycardia.
- D. The patient is pacing the halls.
Correct Answer: A
Rationale: Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Complaining of nausea is an example of subjective data. All other options are examples of objective data.
NANDA International meets to reorganize diagnosis labels and language every 2 ____
Correct Answer: years
Rationale: NANDA International meets every two years to revise language, form, and diagnosis labels.
When the nurse is prioritizing care during the planning phase of the nursing process what is the guiding framework?
- A. Primary
- B. Secondary
- C. Unreliable
- D. Biased
Correct Answer: B
Rationale: Secondary sources include family members.
During an admission assessment the nurse collects objective and subjective data. What is an example of subjective data?
- A. The patient is asleep.
- B. The patient is tearful.
- C. The patient has facial grimacing.
- D. The patient states "I hurt all over."
Correct Answer: D
Rationale: Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Stating 'I hurt all over' is an example of subjective data. All other options are examples of objective data.