The Practical Nurse (PN) uses the “risk for” nursing diagnoses as identified from the: Select all that apply
Client’s problem
Care plan
Evaluation
Assessment
Correct Answer : D
Choice A reason: Needs medical intervention is not the major difference between the two diagnoses. Both diagnoses may require medical intervention, depending on the severity and cause of the vomiting and the nutritional deficiency. Medical intervention is not a criterion for distinguishing between different types of nursing diagnoses.
Therefore, this choice is incorrect.
Choice B reason: Needs no defined nursing interventions is not the major difference between the two diagnoses. Both diagnoses need defined nursing interventions, such as monitoring, teaching, counseling, or providing fluids and electrolytes. Nursing interventions are essential for addressing any nursing diagnosis, whether actual or potential.
Therefore, this choice is incorrect.
Choice C reason: Will not need to be evaluated is not the major difference between the two diagnoses. Both diagnoses need to be evaluated, which involves measuring the outcomes and determining whether the interventions were effective in resolving or preventing the problem. Evaluation is a vital step of the nursing process for any nursing diagnosis, whether actual or potential. Therefore, this choice is incorrect.
Choice D reason: Reflects a problem that does not yet exist is the major difference between the two diagnoses. Diagnosis #1 is an actual nursing diagnosis, which reflects a problem that exists at the present time and has signs and symptoms that can be observed or measured. Diagnosis #2 is a risk for nursing diagnosis, which reflects a problem that does not exist at the present time but may develop in the future if preventive measures are not taken.
Therefore, this choice is correct.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A"]
Explanation
Choice A reason: A desired patient outcome or expected outcome is a goal that the patient and his family ask the nursing staff to accomplish. This ensures that the patient’s needs and preferences are respected and met.
Choice B reason: A desired patient outcome or expected outcome is not a goal that is set slightly higher than the patient can achieve. This would be unrealistic and demotivating for the patient.
Choice C reason: A desired patient outcome or expected outcome is not a goal statement that is observable and measurable. This is a characteristic of a well-writen goal statement, but not a definition of a desired patient outcome or expected outcome.
Choice D reason: A desired patient outcome or expected outcome is a goal that the patient should reach as a result of planned nursing interventions. This shows the link between the nursing process and the patient’s progress.
Correct Answer is ["A"]
Explanation
Choice A reason: Identify outcomes is a step of the nursing process that involves setting measurable and realistic goals for the client’s health improvement or maintenance. The goals are based on the client’s needs, preferences, and values, and they are developed in collaboration with the client and the nurse. Therefore, this choice is correct.
Choice B reason: Planning is a step of the nursing process that involves designing a plan of care that outlines the interventions and activities that will help the client achieve the desired outcomes. The plan of care is also developed in collaboration with the client and the nurse, and it reflects the client’s priorities and resources. Therefore, this choice is correct.
Choice C reason: A “risk for” nursing diagnosis is a type of nursing diagnosis that identifies a potential problem or complication that the client may develop if preventive measures are not taken. It is not a step of the nursing process,
but rather a component of the assessment step, which involves collecting and analyzing data about the client’s health status. Therefore, this choice is incorrect.
Choice D reason: Implementation is a step of the nursing process that involves carrying out the plan of care and performing the interventions and activities that were planned. It also involves monitoring the client’s response and progress, and documenting the outcomes. It is not a step where the goals are developed, but rather where they are executed. Therefore, this choice is incorrect.
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