A nurse is assigned to four patients during a morning shift. Which patient should the nurse perform a focused assessment on first?

A patient who is scheduled for a routine follow-up visit for hypertension management.

A patient who is receiving antibiotics for a urinary tract infection and is requesting assistance with personal hygiene.

A patient who is recovering from an appendectomy and is asking about discharge instructions.

A patient who is complaining of sudden onset chest pain and shortness of breath.

Answer: D

Answer and Explanation

The Correct Answer is D

A. A patient who is scheduled for a routine follow-up visit for hypertension management. This is incorrect because this patient is stable and does not require immediate assessment. Routine follow-ups do not take priority over acute conditions.

B. A patient who is receiving antibiotics for a urinary tract infection and is requesting assistance with personal hygiene. This is incorrect because while personal hygiene is important, it is not urgent or life-threatening.

C. A patient who is recovering from an appendectomy and is asking about discharge instructions. This is incorrect because discharge teaching is important but can be scheduled later in the shift when more urgent needs have been addressed.

D. A patient who is complaining of sudden onset chest pain and shortness of breath. This is correct because sudden onset chest pain and shortness of breath can indicate a life-threatening condition such as myocardial infarction or pulmonary embolism. The nurse must immediately assess this patient to determine the cause and initiate emergency interventions if necessary.

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Correct Answer is A

Explanation

A. Problem identified during assessment. This is correct because in the PIE documentation format, "P" stands for "Problem," which refers to the nursing diagnosis or issue identified based on assessment findings. This section describes the primary concern that requires intervention.

B. Interventions planned for the patient. This is incorrect because interventions are documented under the "I" (Intervention) section of the PIE format, which outlines the nursing actions taken to address the identified problem.

C. Patient’s subjective complaints. This is incorrect because subjective complaints contribute to the assessment but do not represent the complete "Problem" component of the PIE format. The problem should be stated as a nursing diagnosis or issue based on assessment data.

D. Evaluation of care provided. This is incorrect because evaluation belongs under the "E" (Evaluation) section of the PIE format, which describes the patient's response to the interventions provided.

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 B. Caregiver Role Strain, related to depression, as evidenced by constant crying C. Impaired Skin Integrity, related to physical immobility, as evidenced by a skin tear over sacral area D. Bowel Obstruction, related to recent abdominal surgery, as evidenced by nausea, vomiting, and abdominal pain

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."

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A nurse is assigned to four patients during a morning shift. Which patient should the nurse perform a focused assessment on first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When using the PIE format for documentation, which of the following elements should the nurse include under 'P?

Correct Answer is A

Explanation

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

Correct Answer is C

Explanation

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?

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?

Which of the following is the most appropriate open-ended question to begin a nursing assessment?

Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient?

The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?

The nurse manager notices that a staff nurse writes a nursing diagnosis as "Impaired Physical Mobility, related to laziness and not having appropriate shoes." Which issue related to the nursing diagnosis will the nurse manager discuss with the staff nurse?

Which of the following signs is most indicative of impaired skin integrity?

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?