Deck 17: Nursing Diagnosis

Question 1

The nurse uses nursing diagnoses after completion of the client assessment,because they:
1) Are required for accreditation purposes
2) Identify the domain and focus of nursing
3) Assist the nurse to distinguish medical from nursing problems
4) Make all client problems become more quickly and easily resolved

Answer 1

2
After completing the client assessment,the nurse develops nursing diagnoses based on the data obtained.Nursing diagnoses distinguish the nurse's role from that of the physician,and nursing diagnoses help nurses to focus on the role of nursing in client care.Although most state nurse practice acts include nursing diagnosis as part of the domain of nursing practice,nursing diagnoses are not required for accreditation purposes.Medical problems are identified with medical diagnostic statements to treat a disease condition.Nursing diagnoses describe the client's actual or potential response to a health problem that the nurse is licensed and competent to treat.Nursing diagnoses distinguish the nurse's role from that of the physician.Nursing diagnoses may facilitate communication among health professionals,but they do not necessarily allow all client problems to become more quickly and easily resolved.

Question 2

The primary purpose of a nursing diagnosis,according to the nurses,is to:
1) Support the medical plan of care
2) Provide a standardized approach for all clients
3) Recognize the client's response to an illness or situation
4) Offer the nurse's subjective view of the client's behaviors

Answer 2

3
The primary purpose of a nursing diagnosis is to recognize the client's response to an illness or situation.The nurse can then use the nursing diagnosis to select appropriate nursing interventions to achieve positive client outcomes.A nursing diagnosis is based on the client,not on the medical plan of care.Although nursing diagnoses may facilitate communication,it does not mean they provide a standardized approach for all clients.Nursing diagnoses are individualized to meet the client's needs.The primary purpose of nursing diagnoses is not to offer the nurse's subjective view of the client's behaviors.Nursing diagnoses are based on subjective and objective client data and should not include the nurse's personal beliefs and values.

Question 3

Of the following statements,which one is an example of an appropriately written nursing diagnosis?
1) Acute pain related to left mastectomy
2) Impaired gas exchange related to altered blood gases
3) Deficient knowledge related to need for cardiac catheterization
4) Need for high protein diet related to alteration in client nutrition

Answer 3

3
This nursing diagnosis is written correctly.It defines a problem and its etiology.In this case the problem is the client's response to a diagnostic test.A medical diagnosis should not be recorded as the etiology because nursing interventions cannot change the medical diagnosis.It would be appropriate to state acute pain related to impaired skin integrity secondary to mastectomy incision.This nursing diagnosis is written incorrectly because it uses supportive data of the problem as the etiology.This nursing diagnosis does not identify the problem and etiology.It identifies the client's goal rather than the problem.It could be reworded as imbalanced nutrition: less than body requirements related to inadequate protein intake.

Question 4

Of the following statements,which one is an example of an appropriately written nursing diagnosis?
1) Diarrhea related to food intolerance
2) Alteration in comfort related to pain
3) Risk for impaired skin integrity related to poor hygiene habits
4) Potential complications related to insufficient vascular access

Question 5

Which of the following is an appropriate etiology for a nursing diagnosis?
1) Incisional pain
2) Poor hygienic practices
3) Need to offer bedpan frequently
4) Inadequate prescription of medication

Question 6

Which one of the following is a NANDA International nursing diagnosis label?
1) Frequent urination
2) Coughing and dyspnea
3) Risk for impaired parenting
4) Abnormal hygienic care practices

Question 7

The nurse has diagnosed the client's problem as altered elimination.From the database the nurse identifies all the following as appropriate etiologies for this diagnosis except:
1) Poor fiber intake
2) Limited fluid intake
3) Total hip replacement
4) Lower abdominal discomfort

Question 8

Of the following statements,which one is an example of an appropriately written nursing diagnosis?
1) Risk for change in body image related to cancer
2) Cardiac output decreased related to motor vehicle accident
3) Ineffective airway clearance related to increased secretions
4) Potential for injury related to improper teaching in the use of crutches

Question 9

The nursing diagnosis of acute pain falls under which of the following comfort domain classifications?
1) Social comfort
2) Physical comfort
3) Interpersonal comfort
4) Environmental comfort

Question 10

The nurse is concerned that atelectasis may develop as a postoperative complication.Which of the following is an appropriate diagnostic label for this problem,should it occur?
1) Impaired gas exchange
2) Decreased cardiac output
3) Ineffective airway clearance
4) Impaired spontaneous ventilation

Question 11

Of the following statements,which one is an example of an appropriately written nursing diagnosis?
1) Anxiety related to cardiac monitor
2) Pain related to difficulty ambulating
3) Chronic pain related to insufficient use of medication
4) Bedpan required frequently as a result of altered elimination pattern

Question 12

Which one of the following is an appropriate etiology for a nursing diagnosis?
1) Myocardial infarction
2) Cardiac catheterization
3) Abnormal blood gas levels
4) Increased airway secretions

Question 13

A 53-year-old client is seen at the clinic for a yearly physical examination.In evaluating the client's weight,the nurse also considers the age and height.This is an example of:
1) Defining the client problem
2) Recognizing gaps in data assessment
3) Comparing data with normal health patterns
4) Drawing conclusions about the client's response

Question 14

When asked to define "Nursing Diagnosis" the nurse's best response is:
1) "It is the second step in the Nursing Process."
2) "It is the process of defining a client's problems."
3) "It correlates a client's problem with a condition a nurse is competent to treat."
4) "It focuses care a licensed nurse can provide with the identified needs of a client."

Question 15

A diagnostic error can influence the application of the nursing care plan.A likely source for a nursing diagnosis error is if the nurse:
1) Validates the assessment information in the data base
2) Uses the NANDA International list of diagnoses as a primary source
3) Formulates a diagnosis too closely resembling a medical diagnosis
4) Distinguishes the nursing focus instead of other health care disciplines

Question 16

The nurse's initial responsibility in the management of a client's collaborative problem is to:
1) Monitor for changes
2) Advocate for the client
3) Implement interventions
4) Evaluate client outcomes

Question 17

Identify the defining characteristics in the following nursing diagnosis: Altered speech related to recent neurological disturbance,as evidenced by inability to speak in complete sentences.
1) "Altered speech"
2) "As evidenced by"
3) "Recent neurological disturbances"
4) "Inability to speak in complete sentences"

Question 18

The nurse has identified deficient knowledge regarding surgery for a client who is scheduled for an outpatient procedure.Which of the following instructional topics will best minimize the client's anxiety regarding the procedure?
1) Assure the client that preoperative sedation will be administered.
2) Discuss the pre- and postprocedure care that will be provided.
3) Provide a detailed explanation of why the procedure is necessary.
4) Guarantee that family will be regularly updated during the procedure.

Question 19

The nurse recognizes that which one of the following statements is true with regard to the formulation of nursing diagnoses?
1) The diagnosis should identify a "cause and effect" relationship.
2) The diagnosis must remain constant during the client's hospitalization.
3) The etiology of the diagnosis must be within the scope of the health care team's practice.
4) The diagnosis should include the problem and the related contributing conditions.

Question 20

Based on the following information,what would the nurse identify as the most appropriate nursing diagnosis? The client has abnormal breath sounds,dyspnea,an intermittent cough,and variable respiratory rate.
1) Risk for injury
2) Excess fluid volume
3) Ineffective airway clearance
4) Impaired spontaneous ventilation

Question 21

When asked to define the purpose of diagnostic reasoning,the best nursing response is:
1) "Diagnostic reasoning is the foundation of the second step of the nursing process;Nursing Diagnosis."
2) "The diagnostic reasoning process flows from the assessment process and includes decision-making steps."
3) "Diagnostic reasoning includes data clustering,identifying client needs and formulating the diagnosis or problem."
4) "Diagnostic reasoning involves using the assessment collected on a specific client to logically arrive at an appropriate nursing diagnosis."

Question 22

A client newly diagnosed with type 2 diabetes mellitus asks the nurse to explain,"what the diagnosis means." Which of the following rationales best supports the nurse's determination that the client has knowledge deficit rather than a readiness for enhanced knowledge?
1) The client initiated the question.
2) This is a new diagnosis for the client.
3) The client identified a lack of understanding.
4) Type 2 diabetes mellitus is a complicated disease process.

Question 23

Which of the following statements made by the nurse reflects the best understanding of the usefulness of a concept mapping to client care?
1) "Concept maps help me see the whole client,not just individual health problems"
2) "Concept maps can be easily edited to reflect a client's ever-changing health needs."
3) "I need help organizing my assessment data and concept mapping is really good for that."
4) "I like concept mapping because it helps me focus on how the disease processes affect the client"

Question 24

A client expresses concern over a scheduled intravenous pyelogram by stating,"I don't know what to expect." Which of the following nursing diagnoses is most appropriate for this client need?
1) Anxiety related to scheduled diagnostic testing
2) Knowledge deficit regarding need for diagnostic testing
3) Knowledge deficit related to need for intravenous pyelogram
4) Anxiety related to lack of knowledge concerning intravenous pyelogram

Question 25

Which of the following assessment findings best supports the nursing diagnosis of pain in right knee joint related to degenerative process?
1) Paternal family history of osteoarthritis has been reported.
2) Client is observed grimacing when walking to bathroom.
3) Right knee appears edematous when compared to left knee.
4) Client rated the pain felt after walking at a 6 on a scale of 1 to 10.

Question 26

Which of the following statements made by the nurse reflects the best understanding of the usefulness of a concept map to client care?
1) "Concept maps help me see the whole client,not just individual health problems."
2) "Concept maps can be easily edited to reflect a client's ever changing health needs."
3) "I need help organizing my assessment data and concept mapping is really good for that."
4) "I like concept mapping because it helps me focus on how the disease processes affect the client."

Question 27

Which of the following statements made by a nursing student regarding the cultural characteristics of pain requires immediate follow-up by the clinical instructor?
1) "I can tell when my Hispanic clients are in pain."
2) "Moaning is a classic sign of pain in most cultures."
3) "All clients will tell you when they need pain medication."
4) "Chronic pain is difficult to manage especially for the stoic individual."

Question 28

Which of the following assessment findings best supports the nursing diagnosis of Pain in right knee joint related to degenerative process?
1) Paternal family history of osteoarthritis reported
2) Client observed grimacing when walking to bathroom.
3) Right knee appears edematous when compared to left knee
4) Client rated the pain felt after walking at a 6 on a scale of 1-10

Question 29

Which of the following statements best reflects the nurse's understanding of the primary nursing-related purpose of a concept map?
1) To facilitate holistic nursing care
2) To provide visualization of the client's health problems
3) To assist in the identification of client-oriented nursing diagnoses
4) To demonstrate the relationship between the client's various health problems

Question 30

A nursing student expresses some confusion about identifying the appropriate nursing diagnosis for a specific client.Which of the following responses by the clinical instructor is most instructional?
1) "After defining the client's symptomatology,eliminate those nursing diagnoses that are not supported by the database."
2) "Assess your client and then select the nursing diagnosis that has the greatest number of observable defining characteristics."
3) "After assessing the client,compare their symptoms carefully to the defining characteristic of the nursing diagnosis in order to support or eliminate it as applicable."
4) "With experience you will become skilled at identifying the defining characteristics of a nursing diagnosis in your client.Until that time use a nursing diagnosis book to help in the selection process."

Question 31

Which of the following statements best reflects the nurse's understanding of the primary nursing related purpose of a concept map?
1) To facilitate holistic nursing care
2) To provide visualization of the client's health problems
3) Assist in the identification of client-oriented nursing diagnoses
4) Demonstrate the relationship between the client's various health problems

Question 32

Which of the following responses best reflects an understanding of the purpose of the "related to" phrase attached to the diagnostic label deficient knowledge regarding postoperative routines?
1) "To focus on the cause of the client's needs"
2) "To identify the etiology of the client's diagnosis"
3) "To provide for individualization of the nursing interventions"
4) "To communicate the client's deficits to the nursing staff"