what is correct about a nursing diagnosis

ATI RN

Multi Dimensional Care | Final Exam

1. What is correct about a nursing diagnosis?

A. It is a human response to disease, injury, or other stressors.
B. It remains constant as long as the disease is present.
C. It is a way to identify pathology.
D. It is a disease, illness, or injury.

Correct answer: A

Rationale: A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. Choice A is correct because it identifies nursing diagnosis as related to human responses to health conditions or life processes. Choice B is incorrect because nursing diagnoses can change as the patient's condition changes. Choice C is incorrect because a nursing diagnosis is about responses, not just identifying pathology. Choice D is incorrect because a nursing diagnosis is not the same as a disease, illness, or injury; it is a statement about the patient's response to these conditions.

2. A client does not understand why vision loss due to glaucoma is irreversible. What is the best explanation?

A. Once bacterial infection has caused damage, the tissue does not regenerate.
B. Once retinal detachment occurs, it does not return to its normal state.
C. Too many nerve fibers have become ischemic and died, so vision loss is permanent.
D. Glaucoma always leads to permanent blindness.

Correct answer: C

Rationale: The correct answer is C. In glaucoma, the optic nerve damage due to high intraocular pressure leads to permanent vision loss because the nerve fibers do not regenerate. Choice A is incorrect as it discusses bacterial infection, not relevant to glaucoma. Choice B is incorrect because it refers to retinal detachment, not glaucoma. Choice D is incorrect because not all glaucoma cases lead to permanent blindness; vision loss can be prevented or slowed with treatment.

3. The nurse is caring for a client with rheumatoid arthritis one day after shoulder surgery. What would prompt the nurse to call the provider immediately?

A. The client refused her pain medication this morning and is doing physical therapy.
B. The client reports a minor headache and states she takes an over-the-counter pain pill at home.
C. The client reports intermittent flatus and minor abdominal discomfort.
D. The client has paresthesia in her fingers and intense increasing pain in her shoulder.

Correct answer: D

Rationale: In a client with rheumatoid arthritis one day after shoulder surgery, paresthesia in the fingers and intense increasing pain in the shoulder could indicate nerve compression or damage, which are serious post-operative complications. This situation requires immediate attention from the provider to prevent further complications and ensure appropriate management. The other options, such as refusing pain medication, reporting a minor headache, or experiencing minor abdominal discomfort, are important but not as urgent or indicative of potential serious complications as paresthesia in the fingers and intense increasing pain in the shoulder.