Answer to Question 1
Correct Answer: 4
Rationale 1: Prioritizing care must begin with the basic needs. This option is appropriate but does not match the primary need..
Rationale 2: Prioritizing care must begin with the basic needs. This option is appropriate but does not match the primary need.
Rationale 3: Prioritizing care must begin with the basic needs. This option is appropriate but does not match the primary need
Rationale 4: Prioritizing care must begin with the basic needs, in this case, the airway.
Answer to Question 2
Correct Answer: 2
Rationale 1: The second part of the nursing diagnosis statement is the etiology (E)the factors contributing to or probable causes and should be joined to the first part, the problem (P), by the words related to rather than due to.
Rationale 2: The second part of the nursing diagnosis statement is the etiology (E)the factors contributing to or probable causes and should be joined to the first part, the problem (P), by the words related to rather than due to. The phrase related to implies a relationship between the problem and the cause. In this situation, the cause is unknown, but the problem is evident.
Rationale 3: Making an assumption that the cause is psychosomatic is not within the nurse's scope of practice.
Rationale 4: The third part of the nursing diagnosis statement is the manifested by (S) portion, which includes the signs and symptoms not a generalized statement.
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