Compare an actual nursing diagnosis with a risk for nursing diagnosis, recognizing that in the case of the actual nursing diagnosis

the patient is vulnerable to develop the problem

there is no evidence of defining characteristics

a condition is currently present

it is written as a two-part statement

Answer and Explanation

The Correct Answer is C

A. The patient is vulnerable to develop the problem: This describes a risk diagnosis, where the patient has the potential to develop a condition but does not currently have it.

B. There is no evidence of defining characteristics: An actual nursing diagnosis must have defining characteristics (symptoms/signs).

C. A condition is currently present: An actual nursing diagnosis means the condition is already present, with observable signs and symptoms.

D. It is written as a two-part statement: Actual nursing diagnoses use a three-part statement:

Problem (diagnosis)
Etiology (cause)
Signs and Symptoms (evidence)

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Correct Answer is B

Explanation

A. Patient's nursing problem: Nursing problems are identified in assessments, not the actual care documentation.

B. Interventions carried out to meet the patient’s needs: Documentation should include interventions, the time they were performed, and the caregiver’s signature for legal and professional accountability.

C. Patient’s medical problem: Medical problems are diagnosed by physicians, while nurses document care interventions related to nursing diagnoses.

D. The patient's response to the intervention carried out: While patient responses should be documented, this question focuses on recording interventions, not patient reactions.

A. not used by anyone else but the direct care providers B. concise, legal records of all care given and responses C. owned by the patient, who has a right to see the data any time he/she wishes D. confidential information and cannot be taken to court

Correct Answer is B

Explanation

A. Not used by anyone else but the direct care providers: Health records are used by multiple healthcare team members, including billing departments, insurance providers, and legal entities when required.

B. Concise, legal records of all care given and responses: Health records document all care provided, patient responses, and medical decisions. They serve as legal records in case of disputes or audits.

C. Owned by the patient, who has a right to see the data any time he/she wishes: The healthcare facility owns the records, but patients have a right to request access under HIPAA and other legal provisions.

D. Confidential information and cannot be taken to court: Health records can be subpoenaed and used in legal cases, provided they comply with confidentiality laws.

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Compare an actual nursing diagnosis with a risk for nursing diagnosis, recognizing that in the case of the actual nursing diagnosis

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Documenting the type of interventions carried out, the time care was given, and the signature of the care giver results in recording:

Correct Answer is B

Explanation

Patient health care records are:

Correct Answer is B

Explanation

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