When a problem is suspected, but lacks enough data to support it, the nursing diagnosis is:
A wellness nursing diagnosis
A syndrome nursing diagnosis
A ‘risk for’ nursing diagnosis
An actual nursing diagnosis
The Correct Answer is C
Choice A reason: This is incorrect because it shows that the problem is not suspected, but rather the client has a desire to improve or maintain a level of health. A wellness nursing diagnosis describes a potential or actual health state that can be enhanced.
Choice B reason: This is incorrect because it shows that the problem is not suspected, but rather the client has a cluster of related problems that are associated with a specific situation or event. A syndrome nursing diagnosis describes a patern of responses that are linked by a common cause.
Choice C reason: This is correct because it shows that the problem is suspected, but lacks enough data to support it. A ‘risk for’ nursing diagnosis describes a potential problem that may occur if certain risk factors are present.
Choice D reason: This is incorrect because it shows that the problem is not suspected, but rather the client has signs and symptoms that indicate an actual health issue. An actual nursing diagnosis describes a current problem that has been validated by data.
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Correct Answer is C
Explanation
Choice A reason: “Where do you hurt?” is not the best response to the PN’s observations. This response shows closed-ended questioning, which is a communication technique that involves asking questions that require a yes or no answer or a specific piece of information. It also shows confrontation, which is a communication technique that involves challenging or opposing the other person’s statements or behaviors. It may make the client feel defensive, pressured, or misunderstood, and may discourage further communication. Therefore, this choice is incorrect.
Choice B reason: "I am glad you are feeling beter and have no discomfort.” is not the best response to the PN’s observations. This response shows false reassurance, which is a communication technique that involves minimizing or dismissing the other person’s feelings or situation. It also shows inconsistency, which is a communication barrier that involves giving contradictory or conflicting messages. It may make the client feel confused, ignored, or invalidated, and may undermine the trust or rapport between the client and the PN. Therefore, this choice is incorrect.
Choice C reason: "What you are saying and what I am observing don’t seem to match.” is the best response to the PN’s observations. This response shows reflection, which is a communication technique that involves restating or paraphrasing what the client has said to show understanding and clarify meaning. It also shows congruence, which is a communication skill that involves using consistent verbal and nonverbal cues to reinforce the message and avoid confusion or misunderstanding. It helps the client to recognize and explore their own feelings or thoughts, and shows that the PN is atentive, respectful, and empathetic. Therefore, this choice is correct.
Choice D reason: "It makes me uncomfortable when you are not honest with me.” is not the best response to the PN’s observations. This response shows self-disclosure, which is a communication technique that involves sharing personal information or feelings with the other person. It also shows accusation, which is a communication barrier that involves blaming or criticizing the other person for their statements or behaviors. It may make the client feel
guilty, ashamed, or angry, and may damage the relationship or communication between the client and the PN. Therefore, this choice is incorrect.
Correct Answer is C
Explanation
Choice A reason: Collects data is not an activity that the nurse performs during the planning step of the nursing process. Collecting data is an activity that the nurse performs during the assessment step of the nursing process, which involves gathering and analyzing information about the client’s health status, history, and environment.
Therefore, this choice is incorrect.
Choice B reason: Records data is not an activity that the nurse performs during the planning step of the nursing process. Recording data is an activity that the nurse performs during the documentation step of the nursing process, which involves writing or entering the data and findings in the client’s record or chart. Therefore, this choice is incorrect.
Choice C reason: Prioritizes care is an activity that the nurse performs during the planning step of the nursing process. Prioritizing care is an activity that involves ranking the client’s problems, needs, or risks according to their urgency, importance, or potential impact. It helps the nurse to allocate time and resources efficiently, and to address the most critical or significant issues first. Therefore, this choice is correct.
Choice D reason: Carries out interventions is not an activity that the nurse performs during the planning step of the nursing process. Carrying out interventions is an activity that the nurse performs during the implementation step of the nursing process, which involves executing the plan of care and performing the interventions and activities that were planned. Therefore, this choice is incorrect.
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