Deck 35: Nursing Diagnosis and Planning

Question 1

A nurse has completed the data analysis of a client's nursing history. What should be included in the nursing diagnosis?

A) As much information about the client as possible.
B) The cause of the client's illness.
C) The client's response to the illness.
D) Nursing priorities

Answer 1

Nursing priorities

Question 2

Which intervention should the nurse perform as part of the nursing diagnosis process?

A) Direct nursing interventions to meet the client's high-priority needs.
B) Identify the disease or pathophysiology the client is experiencing.
C) Study the physiologic manifestations of the client's illness
D) Establish the cause and nature of the client's illness.

Answer 2

Direct nursing interventions to meet the client's high-priority needs.

Question 3

The client is having problems swallowing fluids and as a result is dehydrated. Which is the most appropriate way of phrasing the problem in a diagnostic statement?

A) "Effect of medication therapy"
B) "Severe throat pain"
C) "Deficient fluid volume"
D) "Difficulty swallowing water"

Answer 3

"Deficient fluid volume"

Question 4

What is the correct sequence when composing a diagnostic statement?
1) Etiology
2) Problem
3) Signs and symptoms

A) 1, 2, 3
B) 2, 3, 1
C) 2, 1, 3
D) 3, 2, 1

Question 5

What is the best description of a nursing diagnosis?

A) Identification of the nursing care problem based on analysis of data
B) Collection of data related to client's condition
C) Formulation of necessary arrangements for client care
D) Measurement of effectiveness of nursing care

Question 6

What is the rationale for the use of the accepted NANDA-I approved nursing diagnoses?

A) Group of medical researchers and educators maintains a list of accepted nursing diagnoses.
B) Provides written guidelines in the approved list to show the difference between a nursing diagnosis from a medical diagnosis.
C) The NANDA-I list identifies the two segments of a diagnostic statement and provides examples of a comprehensive diagnostic statement for use.
D) Words and terms are the actual diagnostic labels on which the entire client-oriented nursing statement is built.

Question 7

What information should be identifiable when reviewing a client's medical diagnosis? Select all that apply.

A) The nursing care problem
B) The disease a person has or is believed to have
C) The physiologic manifestations of the illness
D) A basis for prognosis
E) The foundation for future medical treatment decisions

Question 8

The nurse has analyzed data regarding the client's chief concern. Which information should the nurse include in the nursing diagnosis?

A) Identification of the disease
B) The medical treatment plan
C) Identification of the nursing care problem
D) The cause of the disease

Question 9

A client who has sustained injuries as a result of a car accident is having trouble sleeping and constantly relives the incident. What diagnostic statement should nurse make for this client?

A) Posttrauma response related to the automobile accident AEB nightmares, insomnia
B) Client has nightmares, insomnia related to the automobile accident
C) Client is showing signs of being in a state of shock after automobile accident
D) Posttrauma response related to automobile accident AEB nightmares. Paxil administered.

Question 10

The nurse is preparing a two-part diagnostic statement for a client diagnosed with dyspnea who has been a long-time smoker. What phrasing should the nurse use to document the problem in the diagnostic statement?

A) Impaired breathing pattern
B) Chronic obstructive pulmonary disease
C) Problems in breathing
D) Caused by smoking

Question 11

A nurse is formulating a three-part diagnostic statement for a client who had a motor vehicle accident. The client has bruises on the anterior chest and is unable to move independently when sitting up or lying down. Which diagnostic statement should the nurse document?

A) Impaired mobility of anterior chest related to bruises and swelling AEB motor vehicle accident
B) Impaired mobility of anterior chest related to the motor vehicle accident AEB bruises and swelling
C) Impaired mobility of anterior chest AEB bruises and swelling
D) Impaired movement of the anterior chest related to the motor vehicle accident

Question 12

Which statement accurately describes the correct use of a nursing care plan?

A) The nursing care plan should be created with input only from nurses.
B) The plan is to be primarily followed by the nurse who created it.
C) Individualize the nursing care plan to represent all unique aspects of client care.
D) Provides specific guidelines directed towards the nurse to follow when caring for the client.

Question 13

Which statement accurately guides the nurse when prioritizing nursing diagnoses?

A) Rank nursing diagnoses in terms of importance.
B) Initially focus on the client's social and psychological needs.
C) Focus equally on each medical concern that the client may have.
D) Focus on client's concerns and prioritize accordingly.

Question 14

A nurse is planning the care of a client with a stomach infection and high fever. Which expected outcome should the nurse include for this client?

A) The client will have no problems in voiding.
B) The client's stomachache will gradually lessen.
C) The nurse will observe overall improvement in the client.
D) The client's temperature will come down to normal range in 2 days.

Question 15

Which is the correct sequence for the planning of nursing care?
1) Establishing expected outcomes
2) Setting priorities
3) Writing a nursing care plan
4) Selecting nursing interventions

A) 1, 2, 3, 4
B) 2, 1, 4, 3
C) 3, 1, 4, 2
D) 4, 1, 2, 3

Question 16

A client is admitted to an assisted living facility for continuing memory care for dementia. Who will be involved with the ongoing planning of the client's care at the assisted living center?

A) The admitting nurse maintains responsibility for the nursing care plan.
B) All nurses who work with the client at the assisted living facility
C) All healthcare team members involved in the ongoing care of the client
D) The client and the client's family members assume ongoing responsibility of the client care plan.

Question 17

A client is admitted for complications of a concussion following a motor vehicle accident. Which type of care plan will be implemented for the client?

A) Informal nursing care plan
B) Electronic-generated nursing care plan for concussion
C) Standardized nursing care plan for concussion
D) Individualized nursing care plan

Question 18

A client is admitted to a medical unit for complications of type 1 diabetes mellitus and all the following nursing diagnoses are appropriately included in the care plan. Which nursing diagnosis would be the priority at this time?

A) Ineffective health maintenance related to the complexity of therapeutic regimen
B) Noncompliance related to restrictive lifestyle
C) Imbalanced nutrition: less than body requirements related to inability to use glucose
D) Powerlessness related to perceived lack of personal control

Question 19

Which characteristics must be present in an expected outcome? Select all that apply.

A) Client oriented
B) Specific
C) Reasonable
D) Measurable
E) Unfailing

Question 20

Which nursing diagnosis has the priority?

A) Ineffective airway clearance
B) Risk for injury
C) Risk for suffocation
D) Social isolation

Question 21

A client has developed a swelling in the throat as a result of the medication's side effect. The client is having problems swallowing fluids and has developed dehydration. How should the nurse state the etiology of the problem when creating a diagnostic statement?

A) "Effect of medication therapy"
B) "Severe throat pain"
C) "Deficient fluid volume"
D) "Difficulty swallowing water"