The nurse manager notices that a staff nurse writes a nursing diagnosis as "Impaired Physical Mobility, related to laziness and not having appropriate shoes." Which issue related to the nursing diagnosis will the nurse manager discuss with the staff nurse?
As written, the diagnosis is too complex.
The staff nurse is being judgmental.
The diagnosis is legally questionable.
There is deficiency of supportive data.
The Correct Answer is B
A. The diagnosis is not necessarily complex.
B. Nursing diagnoses should be objective and free from judgment. "Laziness" is subjective and inappropriate.
C. No legal issue is present, but professionalism is lacking.
D. The issue is more about the judgmental phrasing than missing data.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Temperature and bowel sounds are measurable, making them objective data rather than subjective.
B. These symptoms cannot be measured or observed by the nurse; they are based on the patient's personal experience, making them subjective data.
C. While the cough is subjective, the respiratory rate is measurable and therefore objective. Since the option includes both types of data, it is not the best answer.
D. White blood cell count is objective. Pain rating is subjective, but since this option includes both types of data, it is not the best choice.
Correct Answer is B
Explanation
A. Skin feeling warm to the touch. This is incorrect because warmth may indicate inflammation, infection, or increased blood flow, but it does not necessarily mean the skin’s integrity is impaired. Skin integrity refers to the structural intactness of the skin.
B. Presence of a wound with partial-thickness skin loss. This is correct because partial-thickness skin loss indicates that the protective barrier of the skin has been compromised. This is a clear sign of impaired skin integrity, which requires appropriate assessment and intervention to promote healing and prevent infection.
C. Dry skin with no visible lesions. This is incorrect because while dry skin may be at risk for breakdown, it does not indicate that the skin is currently impaired. Intact dry skin still maintains its structural integrity.
D. Slight redness of the skin after applying pressure. This is incorrect because transient redness that disappears after pressure relief is not necessarily a sign of skin breakdown. However, if redness persists (non-blanchable erythema), it may indicate a stage 1 pressure injury, which would then suggest potential skin integrity impairment.
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