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What is a patient problem considered when a problem is suspected but data to support it are lacking?
- A. A syndrome patient problem
- B. An actual patient problem
- C. A "risk for" diagnosis
- D. A possible patient problem
Correct Answer: D
Rationale: A possible patient problem requires additional data to confirm a problem or to complete a data cluster so that it can be related to a NANDA-I label.
You may also like to solve these questions
What is an example of an appropriate Patient problem?
- A. Impaired skin integrity
- B. Skin breakdown noted
- C. Turn patient every 2 hours
- D. The patient has scabies on his back
Correct Answer: A
Rationale: Impaired skin integrity' is an example of a patient problem. 'Skin breakdown noted' is an example of a charting entry, 'turn patient every 2 hours' is a nursing intervention, and 'scabies' is a medical diagnosis.
During an admission assessment the nurse collects objective and subjective data. What is an example of objective data?
- A. The patient is jaundiced.
- B. The patient states "I am nervous."
- C. The patient complains of palpitations.
- D. The patient denies dizziness when ambulating.
Correct Answer: A
Rationale: Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. The patient is jaundiced is an example of objective data. All other options are examples of subjective data.
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.
What best defines the nursing process?
- A. A method to ensure that the health care provider's orders are implemented correctly.
- B. A series of assessments that isolate a patient's health problem.
- C. A framework for the organization of individualized nursing care.
- D. A preset formula for the design of nursing care.
Correct Answer: C
Rationale: The nursing process is a framework by which to organize individualized nursing care.
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.