A nurse assesses a patient who reports chest pain radiating down their arm. The nurse notes the patient is sweating and pale, BP 90/50 mmHg, pulse 120bpm, irregular. When developing the plan of care, what type of nursing diagnosis should the nurse use?

Risk

Actual

Syndrome

Wellness

Answer and Explanation

The Correct Answer is B

A. A risk diagnosis applies when a problem has not yet occurred but is likely. This patient is already experiencing chest pain and hemodynamic instability, requiring an actual diagnosis.

B. The patient has current symptoms of chest pain, sweating, pallor, hypotension, and an irregular pulse, indicating a medical condition (possibly myocardial infarction). This justifies an actual diagnosis.

C. Syndrome diagnoses involve a cluster of related diagnoses, such as frail elderly syndrome. This patient’s case does not meet that definition.

D. Wellness diagnoses focus on improving health, not addressing an active medical crisis.

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Correct Answer is ["A","B","C","E"]

Explanation

A. Teaching about medications. This is correct because providing education to a patient is a direct care intervention, as it involves interaction with the patient to improve their health outcomes.

B. Performing resuscitation. This is correct because resuscitation is a hands-on, immediate intervention aimed at stabilizing a patient, making it a direct care intervention.

C. Inserting a feeding tube. This is correct because placing a feeding tube is a direct intervention that involves a hands-on nursing procedure.

D. Documenting wound care. This is incorrect because documentation is an indirect care intervention. While it is essential for communication and continuity of care, it does not directly affect the patient's condition.

E. Ambulating a patient. This is correct because physically assisting a patient with walking is a direct care intervention that helps prevent complications such as deep vein thrombosis and pneumonia.

A. Delegate nursing care to the assistive personnel. B. Determine the effectiveness of the plan C. Identify patient centered outcomes and goals D. Discuss discharge planning with the social worker

Correct Answer is C

Explanation

A. While delegation is important, it occurs after the nurse establishes patient-centered goals and a care plan.

B. Evaluating the effectiveness occurs later in the nursing process. The nurse must first set goals and interventions before assessing their outcomes.

C. After analyzing data, the next step in the nursing process is planning, which includes setting measurable, individualized goals for the patient.

D. Discharge planning is important but comes later. The nurse must first establish patient goals and care priorities before involving other healthcare team members.

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A nurse assesses a patient who reports chest pain radiating down their arm. The nurse notes the patient is sweating and pale, BP 90/50 mmHg, pulse 120bpm, irregular. When developing the plan of care, what type of nursing diagnosis should the nurse use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

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Correct Answer is C

Explanation

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