A nursing student correctly describes a risk diagnosis by which of the following statements?

A problem that the client is currently experiencing.

A situation in which a problem will likely occur if the nurse does not intervene.

Those situations in which the client does not have a problem but is at a point in which he or she can attain a higher level of health.

Clinical judgments that describe a specific cluster of nursing diagnoses that occur together and have similar interventions.

Answer and Explanation

The Correct Answer is B

A. This is incorrect because it describes an actual nursing diagnosis, not a risk diagnosis.
B. A risk diagnosis describes a situation in which a problem will likely occur if the nurse does not intervene. It identifies a potential health problem that has not yet developed but could occur due to the client’s risk factors.
C. This is incorrect because it describes a health promotion diagnosis, which focuses on enhancing well-being rather than preventing a problem.
D. This is incorrect because it describes a syndrome diagnosis, which is a group of related nursing diagnoses that occur together.

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Correct Answer is C

Explanation

A. Clubbing of the fingers is a chronic finding associated with long-term hypoxia from respiratory diseases such as chronic lung disease or cystic fibrosis, not acute heart failure.
B. Bilateral crepitus suggests air trapping or alveolar collapse, which is more indicative of pneumonia or emphysema, rather than a primary cardiac cause.
C. Bilateral peripheral edema is correct. Dyspnea that worsens when lying flat (orthopnea) and the need for multiple pillows to sleep comfortably are signs of heart failure. Peripheral edema indicates fluid overload due to poor cardiac function.
D. Increased anteroposterior diameter is associated with chronic respiratory conditions like COPD, where lung hyperinflation leads to a "barrel chest" appearance. This is not a typical finding in heart failure.

A. The use of two middle fingers lightly applied to area along the thumb side of the wrist. B. Application of firm pressure on the wrist area along the side of the fifth digit. C. Application of the bell of the stethoscope to the antecubital area of the upper extremity. D. Use of the thumb and index finger to obliterate the area along the thumb side of the wrist.

Correct Answer is A

Explanation

A. Using two middle fingers lightly applied to the thumb side of the wrist is correct. This technique ensures accurate detection of the radial pulse without excessive pressure, which could occlude the artery.
B. Firm pressure on the wrist along the fifth digit (ulnar side) is incorrect because the radial pulse is located on the thumb side of the wrist, not the ulnar side.
C. Using the bell of the stethoscope in the antecubital area is incorrect because this technique is used for blood pressure assessment, not radial pulse assessment.
D. Using the thumb and index finger to obliterate the pulse is incorrect because the thumb has its own pulse, which may lead to inaccurate readings.

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A nursing student correctly describes a risk diagnosis by which of the following statements?

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Naxlex Comprehensive Predictor Exams

A client complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse's examination, what findings will suggest that the cause of this client's dyspnea is due to a heart condition rather than respiratory disease?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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