Question 1

An example of a qualifier within a nursing diagnosis is all of the following except:

Accepted Answer

The qualifier "specific" is not typically used within a nursing diagnosis. The other options (decreased, ineffective, compromised) are commonly used qualifiers in nursing diagnoses.

Question 2

Aetiologies are an important part of nursing diagnosis because:

Accepted Answer

Aetiologies (causes) can vary and may require different interventions. Identifying the cause can help guide treatment and management options.

Question 3

The nurse is reviewing the client's care plan and checking the quality of the nursing diagnosis statements. Criteria to use for guidelines in formulating nursing diagnoses include all of the following except:

Accepted Answer

C

Question 4

The nurse is preparing a care plan for a newly admitted client. The nurse is aware that an actual nursing diagnosis is used when:

Accepted Answer

An actual nursing diagnosis is used when there are the presence of associated signs and symptoms. This means that the nurse has assessed the client and identified a specific problem that is already present and can be addressed through nursing interventions.

Question 5

The nurse has completed the initial assessment of a client and has analysed and clustered the data. The nurse's next step in the diagnostic process is to:

Accepted Answer

The answer of The nurse has completed the initial assessment...

Question 6

A 2-year-old has been admitted to the paediatric unit with a two-day history of vomiting and diarrhoea. Which of the following would be a cue the nurse identifies as being outside the normal standard?

Accepted Answer

A 2-year-old should have attempted to speak and have a vocabulary of a few words. This could indicate a developmental delay and should be assessed by a healthcare provider. The other options are within normal standards for a 2-year-old.

Question 7

The student nurse is learning about the components of a nursing diagnosis. Which statement by the student indicates a need for further instruction?

Accepted Answer

An actual nursing diagnosis does not include the medical diagnosis in the aetiology, as the aetiology refers to the underlying cause or contributing factors of the problem. The medical diagnosis may provide information relevant to the nursing diagnosis, but it is not included as part of the aetiology.

Question 8

A client who has just been diagnosed with pancreatic cancer is quite upset and verbal. The nurse has formulated the following diagnosis: Anxiety, related to unfamiliarity of disease process, manifested by restlessness and tachycardia. The aetiology of this diagnosis is which of the following?

Accepted Answer

The aetiology, or cause, of the diagnosis is the unfamiliarity of the disease process. The anxiety and physical manifestations such as restlessness and tachycardia are the related symptoms.

Question 9

A client has been having pain without any clear pathology for the cause. The X-rays are normal, the client did not have an injury or fall, and there has been no recent trauma. The most appropriately written nursing diagnosis for this client would be which of the following?

Accepted Answer

"Pain related to unknown aetiology" is the most appropriate nursing diagnosis because it acknowledges the presence of pain without attributing it to any specific cause. This diagnosis allows for continued assessment and exploration of potential causes, while also addressing the client's current experience of pain.

Question 10

"Cue clustering" helps the nurse to determine:

Accepted Answer

Cue clustering helps the nurse to group related cues to identify patterns and determine their significance in the client's overall health assessment. It does not directly measure variations from population norms, developmental delay, or positive/negative changes in health status.

Question 11

Accurately written nursing diagnoses do not include:

Accepted Answer

Nursing diagnoses should be written using nursing terminology rather than medical terminology to accurately reflect the nursing perspective and interventions.

Question 12

A nursing student is learning the application of the nursing process to client care. When questioned by the student about the reason for implementing a nursing diagnosis, the nursing professor responds: "The nursing diagnosis statement:

Accepted Answer

Nursing diagnosis describes the client's problems that nurses are educated and licensed to treat. It helps in identifying and prioritizing clients' needs to provide safe and effective care. The nursing process is a systematic approach that includes assessment, diagnosis, planning, implementation, and evaluation. The nursing diagnosis statement guides the plan of care and helps in communication with other healthcare professionals.

Question 13

The student nurse understands that clustering data comes with experience and recognising cues. The best way for this student to recognise patterns or cues in the data is to:

Accepted Answer

The answer of The student nurse understands that clustering data...

Question 14

Nursing diagnoses are different from medical diagnoses and collaborative problems in all of the following except:

Accepted Answer

The answer of Nursing diagnoses are different from medical diagnoses...

Question 15

A client who has just been diagnosed with cancer is quite upset and anxious. The nurse has formulated the following diagnosis: Anxiety, related to unfamiliarity of disease process, manifested by restlessness and tachycardia. This diagnosis is which of the following?

Accepted Answer

The answer of A client who has just been diagnosed...

Question 16

A client is diagnosed with pneumonia and has been hospitalised for several days. A priority nursing diagnosis for this client is which of the following?

Accepted Answer

Ineffective airway clearance is a priority nursing diagnosis for a client with pneumonia as it can lead to respiratory distress and further complications. This is due to increased secretions in the airways as a result of the infection. Altered oral mucous membranes, activity intolerance, and knowledge deficit may also be present in the client with pneumonia but are not the priority nursing diagnosis.

Question 17

A client who has been in a wheelchair for several years is currently experiencing problems with skin breakdown and urinary retention. When formulating a nursing diagnosis, which of the following would be an appropriate selection?

Accepted Answer

An actual nursing diagnosis is appropriate in this case as the client is currently experiencing skin breakdown and urinary retention, indicating a current health problem that needs to be addressed. A syndrome diagnosis is used when a cluster of related problems exists, but cannot be grouped under a single disease entity, which is not applicable in this case. A wellness diagnosis is used when the client has no apparent health problems and is focused on enhancing well-being, which is not applicable in this case. A risk nursing diagnosis is used when there is a potential for a problem to develop, but there is no evidence of the problem currently occurring, which is not applicable in this case as the client is experiencing skin breakdown and urinary retention.

Question 18

A client has been admitted to the cardiac intensive care unit following an acute myocardial infarction. The nurse formulates the following nursing diagnosis: Acute pain, related to tissue damage, secondary to infarction, manifested by pallor, client report, and shallow, rapid breathing. Which of the following would be an example of a collaborative intervention?

Accepted Answer

Administering pain medication for an acute myocardial infarction would require collaboration between the nurse and the healthcare provider. The healthcare provider would need to order the appropriate medication and dosage, while the nurse would be responsible for administering the medication and monitoring the client's response. Educating the client and family, monitoring for changes in the client's condition, and providing a calm, quiet atmosphere are all independent nursing interventions.

Question 19

The nurse has formulated the following diagnosis: Activity intolerance, related to weakness and debilitation, manifested by reports of fatigue after any physical activity. What is the defining characteristic of this label?

Accepted Answer

The defining characteristic of this label is "reports of fatigue" after any physical activity.

Question 20

Which of the following identifies the aetiology component of a nursing diagnosis?

Accepted Answer

The aetiology component of a nursing diagnosis identifies one or more probable causes of the health problem. Option A describes an incomplete data assessment, option B describes the problem statement, and option D describes the related factors.

Quiz 13: Diagnosing