Deck 12: Nursing Assessment and Diagnosis

Question 1

Why does the nurse use nursing diagnoses after completing the client assessment?

A) Nursing diagnoses make it quicker and easier to resolve all client problems.
B) Nursing diagnoses assist the nurse to distinguish medical from nursing problems.
C) Nursing diagnoses are required by law across Canada.
D) Nursing diagnoses identify client problems that have a nursing focus.

Answer 1

D

Question 2

After visiting with a client,the nurse documents the assessment data.Both objective and subjective information have been obtained during the assessment.Which of the following is classified as objective data?

A) Pain in the left leg
B) Elevated BP
C) Fear of surgery
D) Discomfort with breathing

Answer 2

B

Question 3

The client recently became febrile and stated he felt "hot." The nurse takes the client's temperature and finds it to be 38.2°C.In addition,the client's pulse rate is 88 beats per minute,and his blood pressure (BP)is 168/80 mm Hg.Which of the following is an example of subjective data?

A) Pulse rate of 88 beats per minute
B) BP of 168/80 mm Hg
C) The statement regarding his feeling hot
D) Body temperature of 38.2°C

Answer 3

C

Question 4

What is the link between the nursing diagnosis and the medical diagnosis?

A) The time frame of awareness
B) Potential mobility problems
C) Client's chief medical diagnosis and priority assessments
D) Health promotion activities and education to motivate for wellness

Question 5

An alert,oriented adult client is admitted to the medical centre for diagnostic testing.What is the primary source of information when completing an assessment for this client?

A) Client
B) Physician
C) Family member
D) Experienced nurse on the unit

Question 6

Which of the following represents the three phases of a client interview?

A) Introduction, assessment, conclusion
B) Orientation, documentation, database
C) Introduction, controlling, selection
D) Orientation, working, termination

Question 7

Nursing diagnoses meet specific criteria so they accurately reflect both the client's problem and the possible etiology involved.Which one of the following statements is an example of an appropriately written nursing diagnosis?

A) Cardiac output decreased related to motor vehicle accident
B) Potential for injury related to improper teaching in the use of crutches
C) Ineffective airway clearance related to increased secretions
D) Risk for change in body image related to cancer

Question 8

Readiness for enhanced coping related to successful cancer treatment is an example of which type of nursing diagnosis?

A) A risk nursing diagnosis
B) A wellness nursing diagnosis
C) A health promotion nursing diagnosis
D) An incorrectly worded nursing diagnosis, according to NANDA

Question 9

Which one of the following does the nurse recognize as the primary purpose of a nursing diagnosis?

A) Support the medical plan of care.
B) Provide a standardized approach for all clients.
C) Recognize the client's response to an illness or situation.
D) Offer the nurse's subjective view of the client's behaviours.

Question 10

When documenting a comprehensive nursing health history,under which variable would the nurse document the client's number of children?

A) Spiritual
B) Developmental
C) Psychological
D) Sociocultural

Question 11

The nurse seeks to organize the data obtained from the client in a logical manner.What is the term used to describe this organization,which identifies relations between factors and symptoms in the database?

A) Clustering data
B) Validating data
C) Formulating a problem statement
D) Performing a peer review

Question 12

A client states,"I am so depressed." Which of the following interview questions will best elicit more information from the client?

A) "How long have you felt this way?"
B) "Have you ever felt this sad before now?"
C) "What do you think is the cause of your feeling depressed?"
D) "When did you start having feelings of depression?"

Question 13

What is the first step the nurse should take upon beginning the process of data collection?

A) Physical examination
B) Client interview
C) Review of medical records
D) Discussion with other health team members

Question 14

Nursing diagnoses meet specific criteria so they accurately reflect both the client's problem and the possible etiology involved.Which one of the following statements is an example of an appropriately written nursing diagnosis?

A) Acute pain related to left mastectomy
B) Impaired gas exchange related to altered blood gases
C) Anxiety related to uncertainty over surgery
D) Need for high-protein diet related to alteration in nutrition

Question 15

Which of the following is the second step of data analysis?

A) Interpret the data.
B) Recognize a trend by cues.
C) Compare with normal standards.
D) Formulate a reasoned choice.