NR-305:| NR 305 HEALTH ASSESSMENT EXAM 1 (A) QUESTIONS WITH 100% CORRECT ANSWERS| GRADED A+

NR-305:| NR 305 HEALTH ASSESSMENT EXAM 1 (A) QUESTIONS WITH 100% CORRECT ANSWERS| GRADED A+A nursing student reports to a lead charge nurse that his assigned patient seems to be less alert and his blood pressure is lower, dropping from 140/80 to 110/60. The nursing student states, "I believe this is a nursing diagnosis of Deficient Fluid Volume." The lead charge nurse immediately goes to the patient's room with the student to assess the patient's orientation, heart rate, skin turgor, and urine output for last 8 hours. The lead charge nurse suspects that the student has made which type of diagnostic error? Insufficient cluster of cues Disorganization Insufficient number of cues Evidence that another diagnosis is more likely 1 of 40 Term A nurse in a mother-baby clinic learns that a 16-year-old has given birth to her first child and has not been to a well-baby class yet. The nurse's assessment reveals that the infant cries when breastfeeding and has difficulty latching on to the nipple. The infant has not gained weight over the last 2 weeks. The nurse identifies the patient's nursing diagnosis as Ineffective Breastfeeding. Which of the following is the best "related to" factor? Infant crying at breast Infant unable to latch onto the breast correctly Mother's deficient knowledge lack of infant weight gain 2 of 40 Term The patient fell and fractured his hip. He also has diabetes, heart failure, and osteoporosis. Which aspect of the patient's history would a nursing diagnosis focus on? Sudden onset of pain Intertrochanteric hip fracture Degenerative joint disease Left-sided heart failure 3 of 40 Term A nurse assesses a young woman who works part time but also cares for her mother at home. The nurse reviews clusters of data that include the patient's report of frequent awakenings at night, reduced ability to think clearly at work, and a sense of not feeling well rested. Which of the following diagnoses is in the correct PES format? Disturbed Sleep Pattern evidenced by frequent awakening Disturbed Sleep Pattern related to family caregiving responsibilities Disturbed Sleep Pattern related to need to improve sleep habits Disturbed Sleep Pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested 4 of 40 Term A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is diarrhea related to intestinal colitis. This is an incorrectly stated diagnostic statement, best described as: A) Identifying the clinical sign instead of an etiology. B) Identifying a diagnosis based on prejudicial judgment. C) Identifying the diagnostic study rather than a problem caused by the diagnostic study. D) Identifying the medical diagnosis instead of the patient's response to the diagnosis. Cough and shortness of breath Dyspnea or difficulty in breathing Problems caused by smoking (etiology; cause) Correct Answer(s): D In this example intestinal colitis is a medical diagnosis A,C,E C 5 of 40 Term The following nursing diagnoses all apply to one patient. As the nurse adds these diagnoses to the care plan, which diagnoses will not include defining characteristics? Risk for aspiration Acute confusion Readiness for enhanced coping Sedentary lifestyle 6 of 40 Term A nurse interviewed and conducted a physical examination of a patient. Among the assessment data the nurse gathered were an increased respiratory rate, the patient reporting difficulty breathing while lying flat, and pursed-lip breathing. This data set is an example of: Collaborative Data Set Diagnostic Label Related Factors Data cluster 7 of 40 Term