Nokea
What question must the nurse ask when formulating a nursing diagnosis?
- A. What diagnosis did the physician make for this client?
- B. What is the issue that I can solve for this client?
- C. What physician orders will resolve this issue?
- D. What underlying disease does this client have?
Correct Answer: B
Rationale: The correct answer is B: What is the issue that I can solve for this client? When formulating a nursing diagnosis, the nurse should focus on identifying the client's actual or potential health problems that can be addressed through nursing interventions. This question helps the nurse to pinpoint the specific problem or need that requires nursing attention, leading to the development of an effective care plan.
A: Focusing on the physician's diagnosis is not relevant to formulating a nursing diagnosis.
C: Physician orders are important but not directly related to formulating a nursing diagnosis.
D: Identifying the underlying disease is important but not the primary focus when formulating a nursing diagnosis.
You may also like to solve these questions
A patient diagnosed with a mild anxiety disorder has been referred to treatment in a community mental health center. Treatment most likely provided by the center includes
- A. Medical management of symptoms
- B. Daily psychotherapy
- C. Constant staff supervision
- D. Psychological stabilization
Correct Answer: A
Rationale: The correct answer is A: Medical management of symptoms. In mild anxiety disorders, medication like SSRIs or benzodiazepines are commonly used to alleviate symptoms. Psychotherapy may be helpful but is not daily. Constant staff supervision is not necessary for mild cases. Psychological stabilization is too broad and not specific to treatment.
A nurse is required to float to another unit within the hospital where he is asked to care for a client on a ventilator. The nurse is uncomfortable with this assignment, as he has not had a ventilated client since nursing school. What is the nurse's most appropriate response?
- A. Explain to the nursing supervisor the level of discomfort and ask for a different assignment
- B. State that the client's needs are outside the nurse's scope of practice and request a different assignment
- C. Accept the assignment, asking for help when necessary
- D. Request to return to the home unit and send another nurse who can perform the job
Correct Answer: A
Rationale: The correct answer is A: Explain to the nursing supervisor the level of discomfort and ask for a different assignment. This is the most appropriate response because the nurse is being transparent about their discomfort and seeking a solution to ensure quality care for the client. By communicating concerns, the nurse can potentially be given a more suitable assignment or receive additional training. Option B is incorrect as it is important for nurses to continuously learn and adapt to new situations within their scope of practice. Option C is not ideal as the nurse should not take on a task they are uncomfortable with without proper support. Option D is not the best choice as it does not address the issue directly with the supervisor.
A client is found lying on the floor near the bathroom door, stating, 'I thought I could get up on my own.' What information must the nurse document in this situation?
- A. A statement explaining the condition the client was found in, quoting the client's words about the situation
- B. An explanation of how the fall happened and when the physician was notified
- C. An account of the conditions of the room that contributed to the client's fall
- D. A summary of the client's medical history and current medications
Correct Answer: A
Rationale: The correct answer is A because documenting the client's own words provides direct evidence of their condition and thought process at the time of the incident. This helps in understanding the client's perspective and decision-making, which is crucial for providing appropriate care and preventing future falls.
Choice B is incorrect because while it may be important to document how the fall happened and when the physician was notified, it does not directly capture the client's own words and thoughts.
Choice C is incorrect as it focuses on the conditions of the room rather than the client's own account of the situation.
Choice D is also incorrect as it pertains to the client's medical history and medications, which are important but not directly relevant to documenting the client's immediate situation and actions.
A client asks a nurse, 'Do you think I should move back home after this procedure?' and the nurse responds by saying, 'Do you think you should move back home?' What type of therapeutic communication is the nurse representing?
- A. Observation
- B. Reflection
- C. Summarizing
- D. Validating
Correct Answer: B
Rationale: The correct answer is B: Reflection. Reflection involves paraphrasing the client's words to help them explore their feelings and thoughts. In this scenario, the nurse is reflecting the client's question back to them, encouraging self-exploration. Observation (A) involves stating what the nurse sees or hears without interpretation. Summarizing (C) involves condensing information. Validating (D) involves confirming the client's feelings or experiences. The nurse's response does not align with the other options, making reflection the best choice.
Which example best describes a nurse who exhibits moral courage?
- A. A nurse feels angry when a parent refuses important treatment for his child.
- B. A nurse considers seeking help for depression when she feels she cannot meet the needs of her clients in the oncology unit.
- C. A nurse contacts a physician for further orders when he fails to order comfort measures for a client with a terminal illness.
- D. A nurse is frustrated when the laboratory is slow in responding to an order for a stat blood glucose.
Correct Answer: C
Rationale: The correct answer is C because it demonstrates moral courage by advocating for the client's well-being in the face of potential conflict with the physician. By taking action to ensure the comfort of a terminally ill client, the nurse upholds ethical principles. Choice A reflects emotional response, not moral courage. Choice B focuses on personal issues, not professional courage. Choice D involves frustration, not moral courage.