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

Answer and Explanation

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 ["B"]

Explanation

Choice A reason: Maslow’s hierarchy of needs is a framework for prioritizing human needs, but it is not an organized approach for performing a physical examination. A physical examination should be systematic and comprehensive, not based on subjective preferences or assumptions. Therefore, this choice is incorrect.

Choice B reason: A head-to-toe assessment is an organized approach for performing a physical examination that covers all the major body systems and regions. It allows the nurse to identify any abnormalities or changes in the client’s health status and to document the findings in a consistent manner. Therefore, this choice is correct.

Choice C reason: Subjective data collection is the process of obtaining information from the client about their symptoms, feelings, beliefs, and preferences. It is an important part of the nursing assessment, but it is not an organized approach for performing a physical examination. A physical examination requires objective data collection, which involves observing, measuring, and testing the client’s physical signs. Therefore, this choice is incorrect.

Choice D reason: Review of systems is an organized approach for performing a physical examination that focuses on each body system separately and asks specific questions related to its function and problems. It helps the nurse to elicit relevant information from the client and to detect any abnormalities or deviations from normal. Therefore, this choice is correct.

A. Speak slowly and provide brief and simple examples B. Give very complete, detailed explanations of all information C. Get an interpreter or family member to interpret for the nurse as needed D. Speak quickly and avoid eye contact, which could be perceived as threatening

Correct Answer is A

Explanation

Choice A reason: This is correct because it shows that the nurse is respectful and sensitive to the client’s language and cultural needs. Speaking slowly and providing examples can help the client comprehend and retain the information.

Choice B reason: This is incorrect because it shows that the nurse is overwhelming and insensitive to the client’s language and cultural needs. Giving too much information or using complex terms can confuse and frustrate the client.

Choice C reason: This is incorrect because it shows that the nurse is assuming and delegating the responsibility of communication to someone else. Getting an interpreter or a family member may not be necessary or appropriate if the client speaks English. The nurse should communicate directly with the client as much as possible.

Choice D reason: This is incorrect because it shows that the nurse is rude and disrespectful to the client’s language and cultural needs. Speaking quickly and avoiding eye contact can make the client feel ignored or intimidated. The nurse should maintain eye contact and speak at a normal pace.

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When a problem is suspected, but lacks enough data to support it, the nursing diagnosis is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Subjective data provided by the client included complaints of intermitent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as which of the following? (Select all that apply)

Correct Answer is ["B"]

Explanation

The nurse is preparing to explain an upcoming procedure to an English-speaking Latino client. The nurse determines that the best way to verbally communicate with this client is to:

Correct Answer is A

Explanation

A Practical Nurse (PN) is observing a nursing assistant talking to a client who is hearing impaired. The PN should not intervene if which of the following were performed by the nursing assistant during communication with the client: (Select all that apply)

The nurse is changing a client’s dressing. Which observation warrants immediate physician notification?

During a physical examination, the Practical Nurse (PN) discovers that the client demonstrates signs of ﬂushed, dry, hot skin; dry oral mucus membranes; and temperature elevation. The PN will treat these data as the basis of a nursing diagnosis plan, as they represent:

What should the nurse do with linens that have been soiled by a client with hepatitis?

The husband of a client who has a Sengstaken-Blakemore tube states to the nurse, “I thought having this tube down her nose the first time would convince my wife to quit drinking.” The nurse should make which response to the client’s husband? Select one answer

The practical nurse (PN) observes two unlicensed assistive personnel (UAP) turning an older client who had a hip arthroplasty with prosthesis placement four hours ago. Which observation by the PN indicates that the UAPs need additional information about the turning procedure?

When a female client preparing for surgery suddenly bursts into tears, the nurse should take which of the following actions? · Select one answer

Which of the following are approved nursing diagnoses? (Select all that apply)