NUR 111 Introduction to Health Concepts at Cape Fear Community College

Correct Answer:

Risk for infection because of new incision related to episiotomy.

Explanation:

This option is correct because it follows the NANDA format for a risk diagnosis: “Risk for [problem] related to [risk factor].” Risk diagnoses identify potential problems that may develop, so they do not use “as evidenced by.” In this case, the episiotomy incision is an appropriate risk factor for infection.

Why Other Options Are Wrong:

Constipation due to exhaustion manifested by no bowel movement for 2 days.

This is incorrectly worded. “Due to” should be replaced with “related to.” Also, exhaustion is not the best etiology for constipation, making this diagnosis imprecise.

Altered urinary elimination secondary to childbirth as evidenced by inability to void since childbirth.

This is not a correct NANDA label. “Impaired urinary elimination” would be acceptable, but “altered urinary elimination” is not. Also, “secondary to” is not the correct terminology.

Ineffective breast-feeding related to exhaustion secondary to childbirth as evidenced by no observable signs of oxytocin release.

Although “ineffective breastfeeding” is a valid label, the “secondary to” wording is not appropriate, and the defining characteristic (lack of oxytocin release) is not an observable patient symptom but a physiological process, making this diagnosis inaccurate.

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.

Correct Answer:

Discharge care plan.

Explanation:

A discharge care plan is initiated at admission and ensures patients receive coordinated care throughout their hospital stay and beyond. It addresses post-discharge needs, including medications, follow-up appointments, rehabilitation, and community resources. Planning early reduces complications, prevents readmission, and promotes continuity of care as the patient transitions to the next level of health services.

Why Other Options Are Wrong:

Student care plan.

This is designed as a learning tool for nursing students. It emphasizes the nursing process for practice and evaluation but is not a professional plan guiding patient transitions across care settings.

Interprofessional care plan.

While this involves collaboration among healthcare providers, its focus is on current care delivery rather than specifically preparing patients for discharge and linking them with community resources.

Standardized care plan/critical pathway.

These are generalized plans for managing patients with common conditions, providing consistency and efficiency. However, they are not individualized discharge plans that begin at admission and extend beyond hospitalization.

Correct Answer:

Back channeling.

Explanation:

Back channeling is a therapeutic communication technique where the nurse uses verbal and nonverbal cues such as “all right,” “go on,” or nodding to encourage the patient to continue sharing information. It helps demonstrate active listening, supports patient expression, and ensures the patient feels heard without interrupting their flow of communication.

Why Other Options Are Wrong:

Open-ended questions.

This is incorrect because open-ended questions involve asking broad questions that invite elaboration, such as “Tell me more about how you’ve been feeling.” While helpful in interviews, open-ended questions are not the same as short encouraging cues like “go on.”

Probing.

This option is not correct because probing involves asking follow-up or detailed questions to explore information more deeply, such as “Can you describe the pain more specifically?” Back channeling, in contrast, does not seek new information but encourages the client to continue.

Interview techniques.

While back channeling is indeed a type of interview technique, this option is too broad and vague. The question asks for the specific technique demonstrated by phrases like “all right” or “go on,” which directly identifies back channeling.

Correct Answer:

Determining if the medication can be diluted in a beverage.

Explanation:

The nurse demonstrates critical thinking by first considering if the medication can be safely diluted in a beverage. This approach addresses the immediate barrier while maintaining patient compliance and safety. It is a problem-solving step that uses nursing judgment to adapt the medication administration in a way that makes it more acceptable to the client without delaying or compromising treatment.

Why Other Options Are Wrong:

Asking the nurse manager how to approach the situation.

This is not the best first action because the nurse is expected to use critical thinking to address common issues like medication refusal. Seeking managerial input may be necessary later if alternatives fail, but the nurse should first consider safe, independent interventions.

Waiting until the client is more cooperative.

This is unsafe because delaying medication could compromise treatment effectiveness. Essential medications must be given as prescribed, and simply waiting does not resolve the client’s resistance or demonstrate active problem-solving.

Notifying the health-care provider that the client has refused the medication.

While communication with the provider may be required if the nurse cannot resolve the issue, this should not be the first step. Nurses are responsible for exploring safe alternatives before escalating to the provider, making this option premature as the initial action.

Correct Answer:

The client will lose 5 pounds within the next 2 weeks.

Explanation:

Correctly written outcomes must be client-centered, specific, measurable, realistic, and time-bound (SMART criteria). “The client will lose 5 pounds within the next 2 weeks” clearly defines who (the client), what (lose weight), how much (5 pounds), and by when (within 2 weeks). This outcome is measurable and realistic, allowing the nurse to evaluate whether the goal is achieved. It represents a properly constructed desired outcome statement.

Why Other Options Are Wrong:

The client will be adequately hydrated by discharge.

This is incorrect because “adequately hydrated” is vague and not measurable. Adequate hydration could mean different things to different providers. A more specific outcome would state measurable indicators such as urine output, skin turgor, or lab values.

The client will walk better after resting for 10 minutes.

This option is wrong because it is subjective and unclear. “Walk better” does not define measurable progress and cannot be evaluated objectively. Outcomes should specify measurable distances or times, such as “The client will ambulate 50 feet with minimal assistance after 10 minutes of rest.”

The nurse will provide emotional support at least 3 times each day.

This is incorrect because desired outcomes should describe what the client will achieve, not what the nurse will do. Nursing interventions belong in the plan of care, while outcomes must remain client-focused and measurable in terms of client behavior or condition.

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:

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:

Assist the client with feeding.

Explanation:

Maslow’s hierarchy of needs emphasizes that physiological needs, such as food, water, and oxygen, must be met before safety, love/belonging, or self-actualization needs. Assisting the client with feeding addresses a basic survival requirement. Without meeting nutritional needs, higher-level care interventions like ambulation, emotional support, or social interaction cannot take precedence. Therefore, feeding the client is the priority intervention in this scenario.

Why Other Options Are Wrong:

Ambulate the client in the hallway.

This is incorrect because ambulation is important for mobility and overall health but falls under activity and safety, which are higher-level needs. Physiological needs like food and hydration must be addressed before mobility activities are prioritized.

Place the client in wrist restraints.

This option is wrong because restraints are not a therapeutic intervention to meet client needs and should only be used as a last resort to protect safety. They do not address a physiological or immediate survival requirement and are not supported by Maslow’s framework of prioritization.

Allow family members to visit a newly admitted client.

This is incorrect because family visitation supports love and belonging needs, which are higher up in Maslow’s hierarchy. These needs cannot be prioritized over unmet physiological requirements like feeding, which are essential to the client’s immediate survival and health.