Exam 65: Nursing Diagnosis

A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900.The nursing assistant then reports to the nurse that the patient's blood pressure was low when it was taken at 0830.The nursing assistant states she was busy and had not had a chance to tell the nurse yet.The patient begins to complain of feeling dizzy and light-headed.The blood pressure is re-checked and it has dropped even lower.The nurse first made an error in what phase of the nursing process?

After completing a thorough assessment to formulate a patient database,the nurse should proceed to which step of the nursing process?

A nurse assesses that a patient has not voided in 6 hours.Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention?

The nurse is reviewing a patient's database for significant changes and discovers that the patient has not voided in over 8 hours.The patient's kidney function labs are abnormal,and the patient's oral intake has significantly decreased since previous shifts.Which step of the nursing process should the nurse proceed to after this review?

Which diagnosis below is NANDA-I approved?

Which of these selections is an etiology for Acute pain versus a defining characteristic?

A patient presents to the emergency department following a motor vehicle crash and suffers from a right femur fracture.The leg is stabilized in a full leg cast.Otherwise,the patient has no other major injuries,is in good health,and complains only of moderate discomfort.What is the most pertinent nursing diagnosis to be included in the plan of care based on the assessment data provided?

Which nursing diagnostic statement is accurately written for a patient with a medical diagnosis of pneumonia?

One purpose of using standard formal nursing diagnoses in practice is to

A patient exhibits the following symptoms: tachycardia,increased thirst,headache,decreased urine output,and increased body temperature.After analyzing these data,the nurse assigns which of the following nursing diagnoses?

Which of these questions would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea?

Identify the defining characteristics in the nursing diagnosis statement: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days,abdominal distention,and complaints of abdominal pain.

The charge nurse is reviewing a patient's plan of care,which includes the nursing diagnostic statement,Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate to bathroom.The nurse needs to revise which part of the diagnostic statement?

Which of these findings,when evaluating another nurse developing a plan of care,should the charge nurse recognize as a source of diagnostic error?

A new graduate nurse is not sure what the heart sound is that she is listening to on a patient.To avoid diagnostic error,what should the nurse do?

The patient database reveals that a patient has decreased oral intake,decreased oxygen saturation when ambulating,complaints of shortness of breath when getting out of bed,and a productive cough.What are the defining characteristics for the diagnostic label of Activity intolerance?

A patient with a spinal cord injury is seeking to enhance his urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members.The nursing diagnosis Readiness for enhanced urinary elimination is which type of diagnosis?

A patient of Middle Eastern descent has lost 5 lbs during hospitalization and states that the food offered is not allowed in his diet owing to religious preferences.Based on this information,an appropriate nursing diagnostic statement is Imbalanced nutrition: less than body requirements related to

The process of using assessment data gathered about a patient combined with critical thinking to explain a nursing diagnosis is known as