Deck 65: Nursing Diagnosis

Question 1

A patient of Middle Eastern descent has lost 5 lbs during hospitalization and states that the food offered is not allowed in his diet owing to religious preferences.Based on this information,an appropriate nursing diagnostic statement is Imbalanced nutrition: less than body requirements related to

A) Religious preferences.
B) Decreased oral intake.
C) Weight loss.
D) Race and ethnicity.

Answer 1

B
The cause or related to factor in this case is the patient's lack of oral intake due to lack of appropriate food choices.The patient's religious preferences,race,and ethnicity did not cause his weight loss.Ultimately,the lack of food choices and his decreased intake caused him to lose weight.Weight loss is a sign of imbalanced nutrition,not a cause.The weight loss would be noticed during the assessment and would lead to the nursing diagnosis,not in reverse order.

Question 2

A nurse assesses that a patient has not voided in 6 hours.Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention?

A) "Do you feel like you need to use the bathroom?"
B) "Are you able to walk to the bathroom by yourself?"
C) "When was the last time you took your medicine?"
D) "Do you have a safety rail in your bathroom at home?"

Answer 2

A
The nurse must establish that the patient feels the urge and is unable to void.The question "Do you feel like you need to use the bathroom?" is the most appropriate to ask.This question can be answered without knowledge of the diagnosis of Urinary retention.Discussing the ability to walk to the bathroom and asking about safety rails pertain to mobility and safety issues,not to retention of urine.Taking certain medications may lead to urinary retention,but that information would establish the etiology.The question is asking for the nurse to first establish the correct diagnosis.

Question 3

The charge nurse is reviewing a patient's plan of care,which includes the nursing diagnostic statement,Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate to bathroom.The nurse needs to revise which part of the diagnostic statement?

A) Nursing diagnosis
B) Etiology
C) Patient chief complaint
D) Defining characteristic

Answer 3

B
The etiology,or related to factor,of tibial fracture is a medical diagnosis and needs to be revised.The nursing diagnosis is appropriate because the patient is unable to ambulate.The patient's chief complaint is what the patient subjectively states is the problem.No subjective data are included in the diagnostic statement.The defining characteristic (subjective and objective data that support the diagnosis)is appropriate for Impaired physical mobility.

Question 4

One purpose of using standard formal nursing diagnoses in practice is to

A) Form a language that can be encoded only by nurses.
B) Distinguish the nurse's role from the physician's role.
C) Allow for the communication of patient needs to assistive personnel.
D) Help nurses focus on the scope of medical practice.

Question 5

The process of using assessment data gathered about a patient combined with critical thinking to explain a nursing diagnosis is known as

A) Diagnostic reasoning.
B) Defining characteristics.
C) Assigning clinical criteria.
D) Diagnostic labeling.

Question 6

A patient exhibits the following symptoms: tachycardia,increased thirst,headache,decreased urine output,and increased body temperature.After analyzing these data,the nurse assigns which of the following nursing diagnoses?

A) Adult failure to thrive
B) Hypothermia
C) Deficient fluid volume
D) Nausea

Question 7

Identify the defining characteristics in the nursing diagnosis statement: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days,abdominal distention,and complaints of abdominal pain.

A) Decreased gastrointestinal motility
B) Pain medication
C) Abdominal distention
D) Constipation

Question 8

A patient with a spinal cord injury is seeking to enhance his urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members.The nursing diagnosis Readiness for enhanced urinary elimination is which type of diagnosis?

A) Actual
B) Risk
C) Health promotion
D) Wellness

Question 9

A patient presents to the emergency department following a motor vehicle crash and suffers from a right femur fracture.The leg is stabilized in a full leg cast.Otherwise,the patient has no other major injuries,is in good health,and complains only of moderate discomfort.What is the most pertinent nursing diagnosis to be included in the plan of care based on the assessment data provided?

A) Posttrauma syndrome
B) Constipation
C) Urinary retention
D) Acute pain

Question 10

Which of these questions would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea?

A) "What types of foods do you think caused your upset stomach?"
B) "How many bowel movements a day have you had?"
C) "Are you able to get to the bathroom in time?"
D) "What medications are you currently taking?"

Question 11

The nurse is reviewing a patient's database for significant changes and discovers that the patient has not voided in over 8 hours.The patient's kidney function labs are abnormal,and the patient's oral intake has significantly decreased since previous shifts.Which step of the nursing process should the nurse proceed to after this review?

A) Diagnosis
B) Planning
C) Implementation
D) Evaluation

Question 12

Which of these findings,when evaluating another nurse developing a plan of care,should the charge nurse recognize as a source of diagnostic error?

A) Assigning diagnoses while completing the database
B) Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous antibiotics
C) Completing the interview before performing the physical examination
D) Documenting cultural and religious preferences

Question 13

Which nursing diagnostic statement is accurately written for a patient with a medical diagnosis of pneumonia?

A) Risk for infection related to lower lobe infiltrate
B) Risk for deficient fluid volume related to dehydration
C) Impaired gas exchange related to alveolar-capillary membrane changes
D) Ineffective breathing pattern related to pneumonia

Question 14

The patient database reveals that a patient has decreased oral intake,decreased oxygen saturation when ambulating,complaints of shortness of breath when getting out of bed,and a productive cough.What are the defining characteristics for the diagnostic label of Activity intolerance?

A) Decreased oral intake and decreased oxygen saturation when ambulating
B) Decreased oxygen saturation when ambulating and complaints of shortness of breath when getting out of bed
C) Complaints of shortness of breath when getting out of bed and a productive cough
D) Productive cough and decreased oral intake

Question 15

After completing a thorough assessment to formulate a patient database,the nurse should proceed to which step of the nursing process?

A) Diagnosis
B) Planning
C) Implementation
D) Evaluation

Question 16

A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900.The nursing assistant then reports to the nurse that the patient's blood pressure was low when it was taken at 0830.The nursing assistant states she was busy and had not had a chance to tell the nurse yet.The patient begins to complain of feeling dizzy and light-headed.The blood pressure is re-checked and it has dropped even lower.The nurse first made an error in what phase of the nursing process?

A) Assessment
B) Diagnosis
C) Planning
D) Evaluation

Question 17

Which of these selections is an etiology for Acute pain versus a defining characteristic?

A) Complaint of pain as a 7 on a 0 to 10 scale
B) Disruption of tissue integrity
C) Dull headache
D) Discomfort while changing position

Question 18

Which diagnosis below is NANDA-I approved?

A) Sleep disorder
B) Acute pain
C) Sore throat
D) High blood pressure

Question 19

A new graduate nurse is not sure what the heart sound is that she is listening to on a patient.To avoid diagnostic error,what should the nurse do?

A) Assign the nursing diagnosis of Decreased cardiac output.
B) Ask the patient if he has a history of cardiac problems before assigning the diagnosis of Decisional conflict.
C) Check the previous shift's assessment and document what was noted on the last shift.
D) Ask a more experienced nurse to listen also.