A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?

Health promotion

Risk

Problem focused

Collaborative problem

Answer and Explanation

The Correct Answer is A

A. "Readiness for enhanced urinary elimination" is classified as a health promotion diagnosis, indicating the patient’s desire to improve their health condition and adopt new health behaviors.
B. A risk diagnosis is used when there is a potential for problems to occur, not applicable in this scenario as the patient is actively seeking improvement.
C. A problem-focused diagnosis describes an existing problem that requires intervention; this situation reflects readiness for improvement, not an existing issue.
D. A collaborative problem involves potential complications that require both nursing and medical management; this case focuses on the patient's willingness to learn a self-management skill rather than managing a specific medical problem.

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Correct Answer is C

Explanation

A. Cultural values regarding cleanliness vary, so it is inaccurate to assume uniform standards.
B. Judging the patient as placing "little importance" on hygiene due to appearance can lead to biases and does not consider the patient’s routine.
C. Diabetes may necessitate changes in hygiene practices, especially regarding foot care, to prevent complications. Education on optimal hygiene practices is essential for health management in diabetic patients.
D. While personal preferences influence hygiene, they can be adapted with appropriate education and guidance when necessary for health reasons.

A. Notify the health care provider about the patient's desire to donate organs. B. Contact the United Network for Organ Sharing after talking with the patient. C. Instruct the patient to talk with parents about the desire to donate organs. D. Prepare the organ donation form for the patient to sign while still oriented.

Correct Answer is C

Explanation

A. Notifying the health care provider is not the most appropriate first action, as parental consent is needed.
B. Contacting the United Network for Organ Sharing is premature without consent from the parents.
C. Since the patient is a minor, parental consent is generally required for organ donation. Instructing the patient to discuss this desire with their parents is essential for obtaining legal consent.
D. Preparing the organ donation form is also premature, as minors cannot legally consent without parental approval.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A 17-year-old patient, dying of heart failure, wants to have organs removed for transplantation after death. Which action by the nurse is correct?

Correct Answer is C

Explanation

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