NUR 111 Introduction to Health Concepts

Correct Answer:

Build appropriate nursing knowledge by using evidence-based journals.

Verify the data is correct by consulting with the patient and family.

Base the diagnosis on patterns or behaviors over time rather than an isolated incident.

Have a working knowledge of population norms regarding vital signs, laboratory tests, and assessment data.

Explanation:

Avoiding errors in nursing diagnoses requires accurate data collection, critical thinking, and evidence-based practice. Using scholarly journals ensures up-to-date knowledge. Consulting patients and families helps confirm data accuracy. Recognizing patterns over time prevents misdiagnosis based on isolated incidents. Understanding normal ranges for vital signs and lab values helps distinguish between normal and abnormal findings. These steps ensure diagnoses are valid, safe, and individualized.

Why Other Options Are Wrong:

Assign the LPN the responsibilities of developing the nursing plan of care.

This is incorrect because LPNs do not have the scope of practice to independently develop nursing care plans. Responsibility for writing nursing diagnoses and developing the plan of care rests with the registered nurse. Delegating this task to an LPN increases the risk of errors and compromises care quality.

Correct Answer:

Fairness.

Explanation:

The nurse demonstrates fairness by listening to both the family’s complaint and the nursing assistant’s perspective. Fairness as a critical thinking attitude requires impartiality, balanced consideration, and the avoidance of bias before forming conclusions. By seeking out both sides of the situation, the nurse ensures decisions are made objectively and respectfully.

Why Other Options Are Wrong:

Integrity.

While integrity is important in nursing, it refers to adhering to ethical and moral standards. In this scenario, the emphasis is on treating all parties equally, not just upholding values.

Perseverance.

This is incorrect because perseverance relates to determination in solving problems despite obstacles. The nurse’s action here is not about persistence but about impartial judgment.

Discipline.

Discipline involves structured, logical thinking and adherence to best practices. Although important in clinical reasoning, the scenario specifically highlights equal treatment of perspectives, which reflects fairness instead.

Correct Answer:

Pain related to complex factors.

Explanation:

This option is correct because it uses NANDA-approved terminology. “Complex factors” allows for recognition that multiple influences (physical, psychological, or situational) may contribute to the client’s pain, even if diagnostic tests are normal. This provides a professional and measurable basis for care planning.

Why Other Options Are Wrong:

Pain related to unknown etiology.

This wording is not acceptable in nursing diagnoses. Nurses must avoid “unknown” as an etiology because care should be based on observable or modifiable contributing factors.

Pain related to psychosomatic condition.

This is not appropriate terminology and can be stigmatizing. It makes an assumption about the cause of pain rather than focusing on the patient’s current symptoms and contributing factors.

Pain related to client’s report.

The client’s report is evidence of pain (defining characteristic), not a cause. Etiologies should explain contributing factors, not restate the patient’s subjective data.

Correct Answer:

If there are questions you cannot answer, say so and let the patient know that you will return with follow-up answers.

Greet the patient by the name that they prefer to be addressed.

Avoid making the patient tired during the interview. You do not need to complete the interview in one session.

Respect silence and be flexible and open-minded.

Explanation:

Effective interviewing techniques in nursing focus on building trust, respecting the client, and ensuring their comfort. Admitting when you do not know an answer and promising follow-up shows honesty and reliability, which supports the therapeutic relationship. Greeting the patient by their preferred name demonstrates respect and person-centered care. Allowing breaks to prevent fatigue shows sensitivity to the client’s needs. Finally, respecting silence and being open-minded encourages patients to share freely, creating a safe and supportive environment.

Why Other Options Are Wrong:

Sit stiffly and professional in the chair.

This option is incorrect because sitting stiffly creates a barrier between nurse and client, making the interaction feel cold and rigid. Effective communication requires relaxed, open body language that conveys warmth and attentiveness. Stiff posture may increase patient anxiety rather than build rapport. A professional demeanor should come through empathy and listening, not physical rigidity.

At the end of the interview, ask the client to summarize the discussion.

This is incorrect because asking the client to summarize can place unnecessary pressure on them, especially if they are ill, anxious, or fatigued. It is the nurse’s responsibility to validate and recap the information to ensure accuracy and understanding. Clients may feel tested rather than supported if asked to do this. Instead, the nurse should provide a concise summary of the key points.

Login into the computer system when you enter the room so you can document the information as you complete the interview.

This option is inappropriate because focusing on the computer at the start of the interview creates a barrier and reduces eye contact, which weakens rapport. Documentation should be balanced with patient interaction, not prioritized over building trust. Entering the room and immediately logging into a computer sends the message that data entry is more important than the client’s presence. The priority should be person-to-person connection first.

Correct Answer:

The nurse who asks the client if they use any assistive devices to ambulate.

Explanation:

The assessment phase involves collecting both subjective and objective data about the client’s condition. By asking the client whether they use assistive devices to ambulate, the nurse is gathering important information that will guide further decision-making in the care plan.

Why Other Options Are Wrong:

The nurse who turns the client to a more comfortable position.

This is an example of implementation, since the nurse is carrying out an intervention to improve comfort.

The nurse who works with the client to set goals to quit smoking.

This represents the planning phase, where the nurse and client collaborate to establish goals and desired outcomes.

The nurse who determines that the client’s pain was relieved with pain medication.

This demonstrates evaluation, because the nurse is judging whether the intervention (pain medication) was effective.

Correct Answer:

Preventing and observing for symptoms.

Explanation:

A “risk for” nursing diagnosis indicates that the client does not yet have symptoms but is vulnerable to developing them. Therefore, nursing interventions must focus on prevention and careful observation. The nurse’s role is to minimize the chances of the problem occurring and identify early signs quickly to intervene before the condition worsens.

Why Other Options Are Wrong:

Relieving the symptoms.

This is incorrect because “risk for” diagnoses apply to potential problems, not current symptoms. There are no symptoms present to relieve, so interventions must instead focus on prevention and monitoring.

Carrying out the medical orders.

While following provider orders is part of nursing responsibilities, this does not specifically address the principle behind “risk for” diagnoses. Nursing judgment and preventative measures are central to addressing potential problems, not just implementing medical directives.

Client teaching for self-care.

Although client education is always important, it is not the main principle for a “risk for” diagnosis. Teaching can support prevention but the primary focus must be on actively preventing the problem and monitoring for early signs, which is broader than just education.

Correct Answer:

Inductive reasoning.

Explanation:

Inductive reasoning is a clinical decision-making approach where nurses analyze specific pieces of patient data and then draw inferences to reach a conclusion about the patient’s condition. It allows the nurse to move from particular observations, such as symptoms and assessment findings, to a broader understanding of the patient’s status. This process supports accurate clinical judgments based on evidence.

Why Other Options Are Wrong:

Intuition.

This is based on a nurse’s instincts or past experiences rather than a structured review of specific patient data. While intuition can be valuable, it is not the same as systematically drawing inferences from data.

Clinical judgement model.

This is a comprehensive framework involving noticing, interpreting, responding, and reflecting. It goes beyond reviewing specific data and inference-making, making it broader than the concept asked in the question.

Scientific Method.

This refers to a structured process of hypothesis testing in research, not the immediate clinical reasoning process nurses use at the bedside. It is more formal and not typically applied in everyday patient assessment.

Correct Answer:

Initial.

Explanation:

An initial assessment is a comprehensive evaluation conducted upon admission or at the first encounter. It includes a complete health history and physical examination to establish a baseline database for the client. This database guides the development of the care plan and supports future assessments.

Why Other Options Are Wrong:

Problem-focused.

This assessment targets a specific issue or concern, such as pain or a wound, rather than the entire health history.

Emergency.

An emergency assessment is rapid and focused on life-threatening conditions, such as airway or circulation problems. This is not the case here.

Time-lapsed.

Time-lapsed assessments are conducted later to evaluate progress or changes compared with baseline data. This occurs after the initial assessment, not before.

Correct Answer:

Fatigue after physical activity.

Explanation:

In nursing diagnoses, the “as evidenced by” portion identifies the clinical manifestations, or signs and symptoms. Here, the manifestation is the patient’s report of fatigue following physical activity. This is what the nurse observes or the patient expresses, confirming the presence of the problem “activity intolerance.”

Why Other Options Are Wrong:

Activity intolerance.

This is the diagnostic label, not the clinical manifestation. It identifies the nursing problem but does not describe the specific symptom that proves it exists.

Weakness and debilitation.

These are etiological factors contributing to the diagnosis. They explain the underlying cause of the activity intolerance but do not describe the patient’s presenting symptom.

Multiple sclerosis.

This is the medical diagnosis and underlying condition. It explains why the weakness and debilitation occur but does not represent the patient’s actual symptom or manifestation of activity intolerance.