The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?

The patient reports increased pain and limited range of motion

The patient experiences frequent falls and difficulty maintaining balance

The patient is able to independently walk with a walker

The patient has difficulty ambulating without assistance

Answer and Explanation

The Correct Answer is C

A. Increased pain and frequent falls indicate unmet outcomes.
B. Frequent falls indicate unmet outcomes.
C. This demonstrates progress toward independence in mobility.
D. Difficulty ambulating shows ongoing impairment.

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Correct Answer is C

Explanation

A. Inability to Ingest Food, related to imbalanced nutrition: less than body requirements, as evidenced by inadequate food intake, weight less than 20% under ideal body weight. This is incorrect because "Inability to Ingest Food" is not a NANDA-I approved nursing diagnosis.

B. Caregiver Role Strain, related to depression, as evidenced by constant crying. This is incorrect because "depression" is a medical diagnosis and not an appropriate etiology for a nursing diagnosis. Nursing diagnoses should be based on nursing-related causes.

C. Impaired Skin Integrity, related to physical immobility, as evidenced by a skin tear over sacral area. This is correct because it follows the correct NANDA-I format:

Diagnosis: Impaired Skin Integrity

Etiology (related to): Physical immobility

Defining characteristics (as evidenced by): Skin tear over the sacral area

D. Bowel Obstruction, related to recent abdominal surgery, as evidenced by nausea, vomiting, and abdominal pain. This is incorrect because "Bowel Obstruction" is a medical diagnosis, not a nursing diagnosis. Nursing diagnoses focus on patient responses, such as "Risk for Impaired Bowel Elimination."

A. 42 year old who is due to arrive from the emergency room and has experienced a stroke B. 43 year old female who is post operative surgery and is bleeding from their wound C. 82 year old who was admitted several hours ago with pneumonia, is receiving oxygen and needs a complete bath D. 21 year old who had minor hand surgery 24 hours ago needs an assistance to bathe

Correct Answer is D

Explanation

A. This patient is newly admitted and potentially unstable, requiring nursing assessment before delegation.

B. Active bleeding indicates a complication requiring nursing intervention, making this patient inappropriate for delegation.

C. A patient with pneumonia on oxygen requires close monitoring of their respiratory status, which falls under nursing responsibilities.

D. This patient is stable and only needs assistance, making them appropriate for NAP delegation.

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The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing diagnosis is written in the correct format when using NANDA-I taxonomy?

Correct Answer is C

Explanation

After receiving change of shift report, the nurse delegates hygiene care for the caseload of patients. Which patient should the nurse delegate to the nursing assistive personnel (NAP)?

Correct Answer is D

Explanation

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