A nursing student in clinical asks her instructor what the primary purpose of nursing diagnoses is?

What is the appropriate response by the instructor?

Mutually establish desired outcomes of the plan of care

Guide selection of nursing interventions to meet expected outcomes

Establish a database of information for future comparison

Evaluate the effectiveness of the established plan of care

Answer and Explanation

The Correct Answer is B

A. Mutually establish desired outcomes of the plan of care:

While establishing desired outcomes is an important part of the nursing process, nursing diagnoses themselves do not necessarily focus on mutually establishing these outcomes. Nursing diagnoses help identify health problems and needs, which then guide the development of outcomes during the planning phase.

B. Guide selection of nursing interventions to meet expected outcomes:

This is the correct answer. Nursing diagnoses help determine the specific needs and problems a patient is facing. Once identified, nursing interventions can be chosen to address these needs and work towards achieving expected outcomes.

C. Establish a database of information for future comparison:

Establishing a database of information is more related to the assessment phase of the nursing process. Nursing diagnoses are formulated based on the analysis of the collected data and serve to guide subsequent steps in the nursing process, particularly planning and intervention.

D. Evaluate the effectiveness of the established plan of care:

Evaluating the effectiveness of the established plan of care is part of the later stages of the nursing process. Nursing diagnoses help in planning and implementing interventions, and evaluating their effectiveness comes after these interventions have been carried out.

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Correct Answer is B

Explanation

A. Lub-dub sounds:

This describes the normal heart sounds, with the "lub" representing the closing of the mitral and tricuspid valves (S1) and the "dub" representing the closing of the aortic and pulmonic valves (S2). This is the typical and expected sound of a healthy heart.

B. Gentle blowing or swooshing noise:

This describes the characteristic sound of a heart murmur. Murmurs are abnormal sounds caused by turbulent blood flow, and they are often described as a gentle blowing or swooshing noise heard between the normal heart sounds.

C. Scratchy, leathery heart noise:

This description is not typical for heart sounds or murmurs. Heart sounds are usually described in terms of tones, clicks, or swooshing rather than scratchy or leathery.

D. Abrupt, high-pitched snapping noise:

This description is not typical for heart sounds or murmurs. Heart murmurs are generally characterized by a more continuous, blowing, or swooshing quality, rather than abrupt, high-pitched snapping noises.

A. Client reports feeling dizzy when sitting up from a supine position. B. Client reports feeling palpitations when rising from a supine to a standing position. C. Erythema is present on the bilateral lower extremities D. The client has a temperature of 100.4 F E. The client states, “I feel lightheaded when sitting up.”

Correct Answer is ["A","D","E"]

Explanation

A. Client reports feeling dizzy when sitting up from a supine position.

Dizziness or lightheadedness when moving from a lying down to a sitting or standing position can be indicative of orthostatic hypotension.

B. Client reports feeling palpitations when rising from a supine to a standing position.

Palpitations (feeling of rapid or irregular heartbeat) can be associated with orthostatic changes and may indicate the heart's compensatory response to low blood pressure.

C. Erythema is present on the bilateral lower extremities.

Erythema (redness of the skin) is not typically associated with orthostatic hypotension. This symptom is more likely related to skin conditions or other causes.

D. The client has a temperature of 100.4 F.

Fever (elevated body temperature) is not a direct symptom of orthostatic hypotension. Orthostatic hypotension is primarily related to changes in blood pressure upon assuming an upright position.

E. The client states, “I feel lightheaded when sitting up.”

Lightheadedness upon sitting up or standing is a common symptom of orthostatic hypotension.

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A nursing student in clinical asks her instructor what the primary purpose of nursing diagnoses is? What is the appropriate response by the instructor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nursing student is preforming a head-to-toe assessment on his patient with a history of mitral regurgitation. Instead of hearing normal heart sounds the student hears a murmur. Which of the following best describes the sound of a heart murmur?

Correct Answer is B

Explanation

A nurse is taking a blood pressure measurement to assess for orthostatic hypotension in a client. Which signs and symptoms will the nurse assess related to this condition? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

A nurse is assessing a client’s radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

A nurse is auscultating the breath sounds of a client who has congestive heart failure. When the client exhales, the nurse hears bubbling, popping like sounds. The nurse should document this as which of the following adventitious breath sounds?

A nurse is auscultating a client’s lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take?

A nurse is completing a client abdominal assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse?

A client has just been admitted to the postanesthesia care unit (PACU) after having a procedure to bypass arteries in the right leg. Which assessment should receive the highest priority?

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A nurse is assisting with the admission of an alert and oriented client to the orthopedic surgical unit. Which of the following sources of information should the nurse rely on for accurate information about the client?

A nursing student in clinical asks her instructor what the primary purpose of nursing diagnoses is?

What is the appropriate response by the instructor?