Nursing Diagnoses Trivia Quiz Questions!

1. The nurse recieves change of shift report and has been assigned each of these patients. Which one should be assessed first?

A 17 year old patient, 2 days after casting for a radial fracture. He is complaining of severe pain in his arm, his fingers are edematous, and pulses are weak.

A 16 year old boy who is scheduled for a colonoscopy in the morning and has not had his bowel prep.

A 49 year old woman with a history of COPD, admitted for deep vein thrombosis (DVT). She is experiencing chest discomfort and dyspnea.

A 72 year old man who is scheduled for total hip replacement in need of preparation for surgery and has not signed the consent form.

The 49-year-old woman with a history of COPD, admitted for deep vein thrombosis (DVT), should be assessed first. Chest discomfort and dyspnea can be signs of a potential pulmonary embolism, which is a life-threatening condition. Prompt assessment and intervention are crucial to prevent further complications or potential cardiac arrest.

Explanation

The 49-year-old woman with a history of COPD, admitted for deep vein thrombosis (DVT), should be assessed first. Chest discomfort and dyspnea can be signs of a potential pulmonary embolism, which is a life-threatening condition. Prompt assessment and intervention are crucial to prevent further complications or potential cardiac arrest.

2. S. Walker 68 years of age, was admitted for persistent abdominal pain and nausea during the past several weeks. Her history revealed that she stopped using sugar in her coffee to lose weight, with a resultant weight loss of 30 lbs during the past 4 months. Diagnostic testing reveals a colon lesion thought to be malignant, and the patient is scheduled for a colon resection in the morning. Sandra is very anxious after discussing the plan of care and refuses to sign a surgical consent form. Sandra tells the nurse that she is having severe abdominal pain and demands "a pain shot right now" The nurse notes that about 3 hours have passed since her last pain shot. All of the following nursing diagnoses are appropriate to this patient; which one is the priority at this time?

Deficient knowledge related to procedure
Anxiety related to procedure
Acute pain related to the disease process
Risk for imbalanced nutrition related to disease

Deficient knowledge related to procedure

Anxiety related to procedure

Acute pain related to the disease process

Risk for imbalanced nutrition related to disease

The priority nursing diagnosis at this time is "Acute pain related to the disease process." This is because the patient is experiencing severe abdominal pain and is demanding immediate pain relief. Addressing the patient's pain is crucial in providing comfort and promoting their overall well-being. By addressing the acute pain, the nurse can help alleviate the patient's anxiety and potentially increase their willingness to sign the surgical consent form. Additionally, managing the pain will contribute to a more successful surgical outcome.

Explanation

The priority nursing diagnosis at this time is "Acute pain related to the disease process." This is because the patient is experiencing severe abdominal pain and is demanding immediate pain relief. Addressing the patient's pain is crucial in providing comfort and promoting their overall well-being. By addressing the acute pain, the nurse can help alleviate the patient's anxiety and potentially increase their willingness to sign the surgical consent form. Additionally, managing the pain will contribute to a more successful surgical outcome.

3. Which of the following patients should the nurse see first?

A 40 year old 7 day postpartum female with bright red vaginal bleeding and a hemoglobin level of 7.0 g/dL

A diabetic patient with a blood sugar of 400mg/dL and no orders for insulin coverage.

A 46 year old end stage renal disease patient who had an arteriovenous (AV) fistula placement 2 days ago. No thrill or bruit noted.

A 50 year old woman, 2 days after knee replacement. She refuses to use CPM machine due to pain

The 40-year-old postpartum female with bright red vaginal bleeding and a hemoglobin level of 7.0 g/dL should be seen first because she is experiencing significant bleeding and has a low hemoglobin level, indicating potential hemorrhage. This is a critical situation that requires immediate attention to prevent further complications or potential life-threatening situations.

Explanation

The 40-year-old postpartum female with bright red vaginal bleeding and a hemoglobin level of 7.0 g/dL should be seen first because she is experiencing significant bleeding and has a low hemoglobin level, indicating potential hemorrhage. This is a critical situation that requires immediate attention to prevent further complications or potential life-threatening situations.