Question 1

The nursing diagnosis taxonomy provides nursing with:

Accepted Answer

Professions require a sound scientific base; the nursing process is nursing's scientific base. To achieve this scientific foundation, nursing requires a taxonomy, or classification system, to provide a structure for nursing practice.

Question 2

Which of the following is classified as a nursing diagnosis?

Accepted Answer

Grieving is a nursing diagnosis per the latest NANDA Taxonomy. The other choices are medical diagnoses.

Question 3

Nursing diagnoses that require physician-prescribed and nurse-prescribed actions would be what type of problems?

Accepted Answer

If problems require physician-prescribed and nurse-prescribed actions, they are collaborative health problems.

Question 4

In the development of a nursing diagnosis for a client who has cachexia and decreased weight, what would be an appropriate nursing diagnosis?

Accepted Answer

Another common mistake is to write "lack of adequate nutrition" as the nursing diagnosis. The most appropriate nursing diagnosis would be imbalanced nutrition: less than body requirements.

Question 5

What does the nursing diagnosis represent?

Accepted Answer

Each nursing diagnosis represents a pattern of related client cues.

Question 6

What gives additional meaning to a nursing diagnosis?

Accepted Answer

Descriptors are words used to give additional meaning to a nursing diagnosis.

Question 7

What is meant by impaired state of equilibrium?

Accepted Answer

Descriptors such as "impaired state of equilibrium" describe changes in condition, state of the client, or some qualification of the specific nursing diagnosis.

Question 8

What information provides the nurse with accuracy when developing a nursing diagnosis?

Accepted Answer

Each piece of client information is considered a clinical cue; a set of clinical cues forms a cluster that is present if the diagnosis is accurate.

Question 9

One major requirement of a nursing diagnosis is that it focuses on a problem that is:

Accepted Answer

Registered nurses are educated and licensed to make nursing diagnoses. As such, they have a duty to identify and plan care for clients based on them.

Question 10

The act of analyzing and synthesizing cues requires:

Accepted Answer

During clustering, critical thinking is used to analyze and synthesize cues.

Question 11

A nurse sees the client grimace and documents that the client is in pain, without interviewing the client to obtain further cues. The nurse has:

Accepted Answer

The lack of adequate cues is called premature closure.

Question 12

Which statement appropriately identifies a nursing diagnosis reflecting vulnerability of a woman 78 years of age who is confined to bed?

Accepted Answer

An at-risk nursing diagnosis, as defined by NANDA, "describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community."

Question 13

Why is coding important when writing a nursing diagnosis?

Accepted Answer

Coding of nursing diagnoses in computerized systems allows direct reimbursement of nurses.

Question 14

What is the purpose of establishing a nursing diagnosis?

Accepted Answer

Establishment of a nursing diagnosis reflects the synthesis of data gathered during a nursing assessment. Gordon suggested a framework for organizing nursing diagnoses based on functional health, thus offering a convenient way to cluster similar diagnoses.

Question 15

A nurse had identified several nursing diagnoses for a client. Which diagnosis best reflects health promotion?

Accepted Answer

The diagnosis of "readiness" reflects health promotion. The diagnoses about constipation and impaired skin integrity are actual nursing diagnoses. Right hip fracture is a medical diagnosis.

Question 16

Which assessment finding would support the nursing diagnosis of acute pain? Select all that apply.

Accepted Answer

The client crying in pain 1 day after surgery would be expected and lead to a nursing diagnosis of acute pain. Although the client likely experiences pain from the past back surgery and osteoarthritis, it would not support the diagnosis of acute pain. The smoking history does not support the diagnosis.

Question 17

The following nursing diagnosis appears on a clients plan of care: Impaired Physical Mobility related to postoperative pain as evidenced by difficulty ambulating. The nurse identifies the descriptor in this nursing diagnosis as:

Accepted Answer

Descriptors are words used to give additional meaning to a nursing diagnosis. They describe the change in condition, state of the client, or some qualification of the specific nursing diagnosis. The word "impaired" is a descriptor. Physical mobility is the diagnostic label. Postoperative pain denotes the related factor contributing to the problem. Difficulty ambulating denotes the cue that supports the existence of the problem.

Question 18

A nurse is developing a plan of care for a client with a chronic respiratory problem. When developing appropriate nursing diagnoses for this client, the nurse needs to keep in mind that:

Accepted Answer

A nursing diagnosis describes an actual, risk, or wellness-human response to a health problem that nurses are responsible for treating independently. Nursing diagnoses describe the client's response to the disease process, developmental stage, or life process and provide a convenient way to communicate nursing therapies or interventions. Nursing diagnoses carry legal ramifications. Only healthcare problems within the scope of nursing practice can be identified as nursing diagnoses. A nurse cannot diagnose a medical disease and is not licensed to independently treat such a problem. Although nurses may identify a problem, medical diagnoses require validation by the physician that the problem exists. The main focus of a medical diagnosis is on monitoring for pathophysiologic responses of body organs and systems. Medical diagnoses convey information about signs and symptoms of disease and provide a convenient means for communicating treatment requirements.

Question 19

Assessment of a client with difficulty breathing reveals thick, tenacious secretions in the trachea and bronchi and excessive sputum with coughing. The respiratory rate is slightly increased. When developing this client's plan of care, which nursing diagnostic label would be most appropriate?

Accepted Answer

Based on the assessment, the nurse should identify specific cues, such as the thick secretions, excessive sputum, and coughing, which would indicate a problem with a clear airway. Although the client may be experiencing problems with his or her activity level or a disruption in his or her sleep from coughing, there is no indication that either of these is occurring. The client's respiratory rate is increased; however, he or she is breathing independently.

Question 20

A nurse is preparing to write a nursing diagnosis for a client. Which activity would the nurse need to do first?

Accepted Answer

The first step is to look at the data for cues. Significant data or cues will then be clustered. During cue clustering, critical thinking is used to analyze and synthesize the cues; that is, how they fit into a particular problem. The cues are then put together to form meaningful clusters that describe specific client problems. Cluster interpretation involves synthesizing the cue clusters; that is, to see the whole picture and attach meaning to the cluster. Once the nursing diagnosis is selected, it should be validated with the client.

Quiz 7: Nursing Diagnosis