Nokea
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.
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A nurse develops a plan of care to meet the needs of a patient who has had a large loss of blood after a snowmobile crash. The interventions include administering and monitoring the patients physiologic response to intravenous fluids and blood. What has the nurse focused care on?
- A. a medical diagnosis
- B. a nursing diagnosis
- C. a collaborative problem
- D. a goal for care
Correct Answer: C
Rationale: This scenario describes a collaborative problem, as it involves joint interventions between nursing and medical care, such as administering fluids and blood.
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.
A nurse observes a new mother tenderly holding and softly talking to her baby. What does this observation tell the nurse about the babys strengths?
- A. Nothing; this observation is not important.
- B. The mother is just behaving as all mothers do.
- C. A baby is not capable of having strengths.
- D. Nurturing is a strength for developing infants.
Correct Answer: D
Rationale: Positive maternal interaction, such as nurturing, supports the infant's emotional and developmental strengths.
A nurse is reviewing the health history and physical assessment findings for a patient who is having respiratory problems. Of the following data collected, what data from the health history would be a cue to a nursing diagnosis for this problem?
- A. I often have diarrhea after I eat spicy foods.
- B. My skin is so dry I just cant keep from scratching.
- C. I get out of breath when I walk a few steps.
- D. I just feel so bad about myself these days.
Correct Answer: C
Rationale: Shortness of breath is a direct cue to a respiratory-related nursing diagnosis, as it indicates impaired respiratory function.
A nurse completes a health history and physical assessment for an adolescent before he begins football practice. Based on findings, the nurse recommends reinforcing health habits. What conclusion did the nurse reach after interpreting and analyzing the data?
- A. no problem
- B. possible problem
- C. actual problem
- D. clinical problem
Correct Answer: A
Rationale: Recommending reinforcement of health habits suggests no immediate problem was identified, indicating a 'no problem' conclusion.