A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?

Review the patient's activity orders.

Medicate the patient to alleviate discomfort while ambulating.

Ask for at least two other assistive personnel to come to the room.

Offer the patient a walker.

Answer and Explanation

The Correct Answer is A

A. Before assisting a patient, especially one with mobility concerns, the nurse must verify provider orders to determine any restrictions or special considerations.

B. Administering pain medication before knowing activity restrictions could lead to falls or complications.

C. While assistance may be needed, the first priority is to check the patient's activity orders to determine the safest way to proceed.

D. Providing a walker might help, but the nurse must first confirm whether assistive devices are appropriate for the patient.

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Correct Answer is C

Explanation

A. Inability to Ingest Food, related to imbalanced nutrition: less than body requirements, as evidenced by inadequate food intake, weight less than 20% under ideal body weight. This is incorrect because "Inability to Ingest Food" is not a NANDA-I approved nursing diagnosis.

B. Caregiver Role Strain, related to depression, as evidenced by constant crying. This is incorrect because "depression" is a medical diagnosis and not an appropriate etiology for a nursing diagnosis. Nursing diagnoses should be based on nursing-related causes.

C. Impaired Skin Integrity, related to physical immobility, as evidenced by a skin tear over sacral area. This is correct because it follows the correct NANDA-I format:

Diagnosis: Impaired Skin Integrity

Etiology (related to): Physical immobility

Defining characteristics (as evidenced by): Skin tear over the sacral area

D. Bowel Obstruction, related to recent abdominal surgery, as evidenced by nausea, vomiting, and abdominal pain. This is incorrect because "Bowel Obstruction" is a medical diagnosis, not a nursing diagnosis. Nursing diagnoses focus on patient responses, such as "Risk for Impaired Bowel Elimination."

A. Planning B. Assessment C. Implementation D. Evaluation

Correct Answer is B

Explanation

A. Planning. This is incorrect because the planning phase involves setting goals and determining interventions based on the assessment data. Allergy information should be collected before this phase.

B. Assessment. This is correct because the assessment phase involves gathering subjective and objective data about the patient. Asking about allergies is part of the initial health history to ensure safe care planning.

C. Implementation. This is incorrect because the implementation phase involves carrying out interventions based on the data collected in the assessment. Checking allergies before giving medications or treatments should occur earlier.

D. Evaluation. This is incorrect because evaluation involves determining the effectiveness of interventions. Allergy assessment should be completed long before this phase to prevent potential reactions.

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A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing diagnosis is written in the correct format when using NANDA-I taxonomy?

Correct Answer is C

Explanation

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

Correct Answer is B

Explanation

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