Question 1

A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues provide organization or ...

Accepted Answer

These cues are being organized into a pattern that suggests a particular health issue, which is referred to as clustering in the context of nursing and medical diagnosis. Clustering involves grouping related information to help identify patterns that might indicate a specific health problem.

Question 2

Which of the following reflects the diagnosis phase?

Accepted Answer

The diagnosis phase involves identifying health problems after assessment, and option A ("The nurse identifies that the client does not tolerate activity") is an example of diagnosing a problem based on assessment findings.

Question 3

The nurse is providing care for a client who experienced an ischemic stroke five days ago. Which of the following diagnoses would the nurse be justified in identifying and documenting in the care of this client? Select all that apply.

Accepted Answer

The answer of The nurse is providing care for a...

Question 4

A nursing diagnosis is written as Disturbed Self-Esteem related to presence of large scar over left side of face. What does the phrase "Disturbed Self-Esteem" identify?

Accepted Answer

The phrase "Disturbed Self-Esteem" identifies the health state or problem of the client, indicating the issue the nursing diagnosis aims to address.

Question 5

A client who has to undergo a parathyroidectomy is worried that he may have to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan?

Accepted Answer

The client's concern about having to wear a scarf following parathyroidectomy indicates a potential disturbance in body image related to scarring. This would be the most appropriate nursing diagnosis to document in the care plan. The other options are not directly related to the client's concern about postoperative appearance.

Question 6

Of all the benefits of using nursing diagnoses, which one is probably the most important to nurses?

Accepted Answer

The answer of Of all the benefits of using nursing...

Question 7

A nurse who is caring for an unresponsive client formulates the nursing diagnosis, "Risk for Aspiration related to reduced level of consciousness." The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis?

Accepted Answer

Risk for Aspiration related to reduced level of consciousness is a two-part statement, with the first part identifying the potential problem (Risk for Aspiration) and the second part identifying the contributing factors (related to reduced level of consciousness).

Question 8

A nurse is formulating a diagnosis for a client who is reliving a brutal mugging that took place several months ago. The client is crying uncontrollably and states that he "can't live with this fear." Which of the following diagnoses for this client is correctly written?

Accepted Answer

Post-traumatic stress disorder (PTSD) is a common diagnosis for individuals who have experienced a traumatic event, such as a mugging. Symptoms may include reliving the event, avoidance of triggers, and heightened anxiety. Option A, "Post-trauma syndrome related to being attacked", is a correct and specific diagnosis that addresses the client's symptoms and the cause of their distress.

Question 9

In the nursing diagnosis Disturbed Self-Esteem related to presence of large scar over left side of face, what part of the nursing diagnosis is "presence of large scar over left side of face"?

Accepted Answer

"Presence of large scar over left side of face" is the etiology or underlying cause of the disturbed self-esteem.

Question 10

A student identifies Fatigue as a health problem and nursing diagnosis for a client receiving home care for treatment of metastatic cancer. What statement or question would be best to validate this client problem?

Accepted Answer

This choice asks for the client's input and allows them to agree or disagree with the identified problem, making it a more patient-centered approach. Options A and B are not patient-centered and do not involve the client in the process. Option C sounds judgmental and could put the client on the defensive.

Question 11

What is the nurse accountable for, according to the state nurse practice act?

Accepted Answer

The answer of What is the nurse accountable for, according...

Question 12

After assessing a client, the nurse formulates several nursing diagnoses. Which of the following would the nurse identify as an actual nursing diagnosis?

Accepted Answer

An actual nursing diagnosis refers to a current problem that the client is experiencing and requires nursing intervention. Impaired urinary elimination represents a current problem that requires intervention, whereas readiness for enhanced sleep, risk for infection, and possible impaired adjustment represent potential or future problems that may require intervention.

Question 13

According to Maslow's hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure?

Accepted Answer

According to Maslow's hierarchy of needs, physiological needs (such as breathing and elimination) and safety needs (such as effective coping) take priority over psychological needs (such as body image disturbance). Therefore, the lowest priority nursing diagnosis for a client with congestive heart failure in the intensive care unit would be the risk for body image disturbance.

Question 14

A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling makes his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client's concern?

Accepted Answer

The client's concern about the appearance of his leg with the external fixation device and swelling indicates a disturbance in body image, which should be documented as the nursing diagnosis. Impaired physical mobility may be a relevant nursing diagnosis, but it is not related to the client's concern about the appearance of his leg. Risk for infection and risk for social isolation are not relevant based on the information provided.

Question 15

Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics?

Accepted Answer

An actual nursing diagnosis is validated by the presence of major defining characteristics, which are clinical cues, signs, and symptoms that support the diagnosis. Risk nursing diagnoses are based on the presence of risk factors but do not have any defining characteristics yet. Possible nursing diagnoses are suspected but require further data collection to confirm. Wellness diagnoses are clinical judgments of an individual's overall wellness and may not have any defining characteristics.

Quiz 12: Diagnosing