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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Dorsal surface of the foot:
The skin on the dorsal surface of the foot may have more pigmentation, making it potentially more challenging to detect cyanosis in individuals with dark skin.
B. Pinnae of the ears:
The ears may have variable pigmentation, and the presence of hair can affect the visibility of cyanosis. The skin on the pinnae may not be as thin as the skin on the dorsal surface of the hand.
C. Dorsal surface of the hand
When assessing for cyanosis in a client with dark skin, the nurse should examine areas with less pigmentation or areas where the skin is thin. The dorsal surface of the hand is often a suitable site, as it is less pigmented and can show bluish discoloration if cyanosis is present.
D. Conjunctivae:
The conjunctivae (the mucous membranes lining the inner surface of the eyelids and covering the white part of the eyes) are not a reliable site for assessing cyanosis in individuals with dark skin. Mucous membranes may not show cyanosis as prominently as the skin.
Correct Answer is D
Explanation
A. Wheezes:
Wheezes are high-pitched, musical sounds that occur during inspiration or expiration and are often associated with narrowed airways, such as in conditions like asthma or chronic obstructive pulmonary disease (COPD).
B. Stridor:
Stridor is a high-pitched, crowing sound that is typically heard during inspiration and can be associated with upper airway obstruction, such as in croup or epiglottitis.
C. Rhonchi:
Rhonchi are low-pitched, snoring or rattling sounds that can occur during inspiration or expiration. They are often associated with the presence of mucus or other airway obstruction and can be heard in conditions like bronchitis or pneumonia.
D. Crackles:
Crackles are bubbling, popping sounds heard during inspiration or expiration. They can be further classified as fine or coarse. Fine crackles are often associated with conditions like pulmonary fibrosis, while coarse crackles can be heard in conditions like congestive heart failure or pneumonia.
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