Question 1

The nurse is formulating a nursing diagnosis for a patient. Which definition most accurately describes nursing diagnoses?

Accepted Answer

Nursing diagnoses focus on identifying a client's response to actual or potential health problems or life processes. They are distinct from medical diagnoses, which identify diseases or medical conditions. Nursing diagnoses guide nursing interventions to address the patient's individual responses or vulnerabilities rather than treating a medical condition directly.

Question 2

The nurse is providing care for various patients in an acute care facility. Which patient issue is a problem that nurses can treat independently?

Accepted Answer

Nurses can independently manage symptoms like nausea through non-pharmacological interventions (e.g., repositioning, providing a cool cloth, ensuring adequate ventilation) and administering prescribed antiemetics as part of their scope of practice. The other options typically require a physician's intervention for orders or changes in the treatment plan.

Question 3

The nurse has diagnosed Decisional Conflict related to unclear personal values and beliefs, and the patient shows the necessary defining characteristics. Which essential action does the nurse take to help ensure the accuracy of this diagnosis?

Accepted Answer

Asking for the patient's confirmation of the diagnosis ensures that the nurse's understanding aligns with the patient's experiences and feelings, directly involving the patient in their care and confirming the accuracy of the diagnosis.

Question 4

The nurse manager notices that a staff nurse writes a nursing diagnosis as "Impaired Physical Mobility, related to laziness and not having appropriate shoes." Which issue related to the nursing diagnosis will the nurse manager discuss with the staff nurse?

Accepted Answer

The use of the term "laziness" in the nursing diagnosis is judgmental and not appropriate. Nursing diagnoses should be based on objective assessment data and should not include personal judgments about the patient's character or motivations.

Question 5

Which of the following is an example of what the nurse recognizes as a cluster of related cues?

Accepted Answer

A cluster of related cues involves signs and symptoms that are directly related to each other, indicating a potential problem or condition. In this case, complaints of nausea and stomach pain after eating are related symptoms that could indicate a gastrointestinal issue, making them a cluster of related cues.

Question 6

A patient verbalizes an overwhelming lack of energy, stating, "I still feel exhausted even after sleeping. I feel guilty when I can't keep up with my usual daily activities, or I sleep during the day. I've been a little depressed lately, too." The nurse notes the patient's difficulty concentrating but does not note any apparent physical problems. Which diagnoses best describes the patient's health status?

Accepted Answer

Fatigue is a common symptom of depression. The patient's verbalization of feeling exhausted even after sleeping, feeling guilty about not being able to keep up with usual activities, and sleeping during the day are all consistent with fatigue related to depression.

Question 7

Which nursing diagnosis is written in the correct format?

Accepted Answer

The nursing diagnosis is written in the correct format because it includes the problem (Imbalanced Nutrition: Less than Body Requirements), the etiology (related to body weight less than 20% under ideal weight), and the defining characteristics (body weight less than 20% under ideal weight).

Question 8

The nurse has relocated to a different state and has accepted a position as a staff nurse on an acute care nursing unit. The patient care team consists of both registered nurses (RNs) and licensed practical nurses/licensed vocational nurses (LPNs/LVNs). Which action by the nurse constitutes a possible theoretical error?

Accepted Answer

Formulating a nursing diagnosis is typically within the scope of practice for registered nurses (RNs) and not licensed practical nurses/licensed vocational nurses (LPNs/LVNs). This task requires a higher level of education and training in assessment and diagnosis that RNs receive.

Question 9

The nurse has gathered information about a client, has sorted the information, and is preparing to identify the diagnostic label, or patient problem. For which purpose are diagnostic labels primarily used?

Accepted Answer

Diagnostic labels are primarily used to set client goals.

Question 10

Which statement made by the nurse is an example of stereotyping?

Accepted Answer

Statement A is an example of stereotyping because it makes a broad generalization about patients with a Japanese background, suggesting they all share the same emotional expression, which is not accurate for every individual.

Question 11

The nurse is applying the nursing process to the development of a plan of care for a patient. Based on the patient's problems, the nurse is using Maslow's Hierarchy of Needs. Which nursing diagnosis does the nurse recognize as having the highest priority?

Accepted Answer

Risk for Aspiration is prioritized highest according to Maslow's Hierarchy of Needs because it directly impacts the patient's physiological safety, which is foundational and must be addressed before other needs.

Question 12

Which of the following is the best example of a nursing diagnosis statement?

Accepted Answer

The answer of Which of the following is the best...

Question 13

Which nursing diagnosis is written in the correct format when using NANDA-I taxonomy?

Accepted Answer

NANDA-I taxonomy for writing nursing diagnoses includes three parts: the problem (diagnosis), the etiology (related to), and the symptoms (as manifested by or AMB). Option C, "Impaired Skin Integrity, related to physical immobility, AMB skin tear over sacral area," correctly follows this format.

Question 14

The nurse works in an extended care facility. The residents are primarily older adults with health factors that put them in danger of falling. Which option best describes the type of nursing diagnosis the nurse is likely to use?

Accepted Answer

A risk diagnosis is appropriate in this scenario because it is based on the assessment of the patients' health factors and environment, which indicate a potential for falling. This type of diagnosis is used when there is an increased potential for a problem to develop due to the patients' current health status and conditions.

Question 15

The nurse documents in a patient's progress notes: "Admitted to emergency department accompanied by spouse. Patient is alert and oriented, blood pressure is 120/80 mm Hg, and pulse is 80 beats/min. The patient is anxious and becomes nervous when asked about a smoking history." Which statement from the nurse's note is the best example of an inference?

Accepted Answer

The statement that the patient is anxious is an inference because it is a conclusion reached based on the patient's behavior and reactions, rather than a directly observed or measured fact.

Question 16

A staff nurse states, "I get tired of all the paperwork about nursing diagnosis and plans for patient care." Which of the following describes the most important purpose for developing a nursing diagnosis?

Accepted Answer

The most important purpose of developing a nursing diagnosis is to describe the client's needs for nursing care. This allows for the planning and delivery of individualized and appropriate care.

Question 17

A client's weight is appropriate for the client's height, and laboratory values and other assessments reflect normal nutritional status. However, the client states, "I probably eat a little too much red meat. And, what is this I hear about needing omega 3 oils in my diet? I don't like to take supplements, and I think I could really improve my nutrition." Which nursing diagnoses does the nurse use?

Accepted Answer

The correct answer is "Readiness for Enhanced Nutrition" because the client's nutritional status is currently normal, but the client expresses a desire to improve their nutrition, indicating a readiness to enhance their nutritional health.

Question 18

When making a diagnosis using NANDA-I taxonomy, which part of the statement provides support for the diagnostic label you choose?

Accepted Answer

Defining characteristics provide the evidence or symptoms that support the use of a specific diagnostic label in the NANDA-I taxonomy.

Question 19

Which of the following describes the difference between a collaborative problem and a medical diagnosis?

Accepted Answer

A collaborative problem necessitates the combined efforts of the nurse, physician, and possibly other healthcare professionals for intervention, whereas a medical diagnosis specifically requires a physician's intervention for treatment.

Question 20

The nurse is aware that which approach is best to validate a clinical inference?

Accepted Answer

Having sufficient supportive data is the best approach to validate a clinical inference because it ensures that the inference is based on objective, measurable evidence rather than subjective opinions or observations.

Quiz 4: Analysisdiagnosis