Deck 4: Nursing Process: Diagnosis

Question 1

How does a risk nursing diagnosis differ from a possible nursing diagnosis?

A) A risk diagnosis is based on data about the patient.
B) A possible diagnosis is based on partial (or incomplete) data.
C) Nurses collect the data to support risk diagnoses.
D) A possible diagnosis becomes an actual diagnosis when symptoms develop.

Answer 1

A possible diagnosis is based on partial (or incomplete) data.

Question 2

Which of the following is the best approach to validate a clinical inference?

A) Have another nurse evaluate it
B) Have the physician evaluate it
C) Have sufficient supportive data
D) Have the client's family confirm it

Answer 2

Have sufficient supportive data

Question 3

Which of the following is an example of a problem that nurses can treat independently?

A) Hemorrhage
B) Nausea
C) Fracture
D) Infection

Answer 3

Nausea

Question 4

Based only on Maslow's Hierarchy of Needs,which nursing diagnosis should have the highest priority?

A) Self-Care Deficit
B) Risk for Aspiration
C) Impaired Physical Mobility
D) Functional Urinary Incontinence

Question 5

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

A) Pain related to appendicitis
B) Fractured left leg related to impaired mobility
C) Impaired mobility related to fractured left leg
D) Acute pain related to out of bed activities

Question 6

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

A) Blood pressure reading 120/80 mm Hg
B) Patient is accompanied by wife.
C) Patient has a history of smoking.
D) The patient is anxious.

Question 7

Which of the following is an example of a cluster of related cues?

A) Complains of nausea and stomach pain after eating
B) Has a productive cough and states stools are loose
C) Has a daily bowel movement and eats a high-fiber diet
D) Respiratory rate 20 breaths/min, heart rate 85 beats/min, blood pressure 136/84 mm Hg

Question 8

The diagnostic label,or patient problem,is used primarily to suggest:

A) Client goals
B) Cue clusters
C) Interventions
D) Etiology

Question 9

The client's weight is appropriate for his height.His laboratory values and other assessments reflect normal nutritional status.However,he has told the nurse,"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 of the following nursing diagnoses should the nurse use?

A) Balanced Nutrition
B) Possible Imbalanced Nutrition: Less Than Body Requirements
C) Risk for Imbalanced Nutrition: Less Than Body Requirements
D) Readiness for Enhanced Nutrition

Question 10

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

A) Etiology
B) Related factors
C) Diagnostic label
D) Defining characteristics

Question 11

Which nursing diagnosis is written in the correct format?

A) Imbalanced Nutrition: Less than Body Requirements related to body weight less than 20% under ideal weight
B) Ineffective Airway Clearance related to increased respiratory rate and irregular rhythm
C) Impaired Swallowing related to absent gag reflex
D) Excess Fluid Volume related to 3 lb weight gain in 24 hours

Question 12

What is wrong with the following diagnostic statement? "Impaired Physical Mobility related to laziness and not having appropriate shoes." The statement is:

A) Judgmental
B) Too complex
C) Legally questionable
D) Without supportive data

Question 13

Which of the following most accurately describes nursing diagnoses? A nursing diagnosis:

A) Supports the nurse's diagnostic reasoning
B) Supports the client's medical diagnosis
C) Identifies a client's response to a health problem
D) Identifies a client's health problem

Question 14

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

A) Bowel Obstruction related to recent abdominal surgery AMB: nausea, vomiting, and abdominal pain
B) Inability to Ingest Food related to imbalanced nutrition: less than body requirements A.M.B. inadequate food intake, weight less than 20% under ideal body weight
C) Impaired Skin Integrity related to physical immobility AMB skin tear over sacral area
D) Caregiver Role Strain related to alienation from family and friends AMB 24-hour care responsibilities

Question 15

Which of the following is a criticism of standardized nursing diagnoses developed by NANDA-I?

A) There is little research to support nursing diagnosis labels.
B) A perfect nursing diagnosis must be written for it to be useful.
C) Standardized diagnoses are not included in all states' nurse practice acts.
D) Other professions do not recognize nursing diagnoses.

Question 16

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

A) Ask a more experienced nurse to confirm it.
B) Request a social worker interview the patient.
C) Ask the patient to confirm the diagnosis.
D) Read about Decisional Conflict in the NANDA-I handbook.

Question 17

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

A) A collaborative problem is treated by the nurse; a physician is responsible for the treatment of a medical problem.
B) A collaborative problem is a nursing diagnosis that requires specific orders from a physician; a medical diagnosis directs all nursing care.
C) A collaborative problem has the potential to become an actual nursing diagnosis; a medical diagnosis rarely changes.
D) A collaborative problem requires intervention by the nurse and physician or other professional; a medical diagnosis requires intervention by a physician.

Question 18

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

A) "Be sure to take your shoes off when entering a Japanese family's home."
B) "Patients with type 1 diabetes do not make insulin; therefore, they will need to take insulin regularly."
C) "The patient in room 3 cries every time she gets out of bed. She needs to understand that getting out of bed is helping her."
D) "My 2-year-old child never had a temper tantrum. I don't understand why the 2-year-old child in room 4 is having one."

Question 19

Which of the following describes the most important use of making a nursing diagnosis? Assume all are true.

A) Differentiates the nurse's role from that of the physician
B) Identifies a body of knowledge unique to nursing
C) Helps nursing develop a more professional image
D) Describes the client's needs for nursing care

Question 20

The patient verbalizes an overwhelming lack of energy.He says,"I still feel exhausted even after I sleep.I feel guilty when I can't keep up with my usual daily activities or sleep during the day.I've been a little depressed lately,too." The patient seems to have difficulty concentrating,but has no apparent physical problems.Which of the following diagnoses best describes his health status?

A) Fatigue related to depression
B) Fatigue related to difficulty concentrating
C) Guilt related to lack of energy
D) Chronic confusion related to lack of energy

Question 21

Which of the following reflects the most accurate use of an etiology?

A) Knowledge deficit related to abdominal ultrasound
B) Knowledge deficit related to incorrect use of walker
C) Knowledge deficit related to diabetes
D) Knowledge deficit related to age

Question 22

Which of the following nursing diagnosis statements,using the three-part format (PES),are correct? Select all that apply.

A) Chronic pain related to osteoarthritis AMB rates pain at 8 on a 0 to 10 pain scale and has difficulty with ambulation.
B) Ineffective airway clearance related to excessive mucus AMB cough, shortness of breath, change in respiratory rate and rhythm
C) Caregiver role strain related to increasing care needs AMB wife states, "He is just getting too heavy for me to lift"
D) Anxiety (moderate) related to cardiac catheterization AMB crying and yelling at family members

Question 23

The benefits for nursing practice in using a standardized nursing language include which of the following? Select all that apply.

A) Define and communicate nursing knowledge
B) Assist the nurse in understanding medical diagnoses
C) Facilitate nursing research
D) Help nurses provide consistent interventions for all patients

Question 24

The nurse receives the following report on four patients on the medical-surgical unit.Which patient will the nurse attend to first?

A) Gait unsteady, uses walker, needs 2-person assist with ambulation
B) Abdominal wound is draining foul-smelling fluid, incision margins are red, heart rate 100 beats/min
C) Blood pressure 90/50 mm Hg, heart rate 40 beats/min, rates chest pain at 8 on a 0 to 10 pain scale
D) Verbalizes history of migraine headaches, eyes closed during assessment interview

Question 25

Which of the following regarding nursing diagnosis are accurate? Select all that apply.

A) Provide the basis for nursing interventions
B) Are validated with patient and family when possible
C) Have historically been well substantiated by research
D) Are descriptions of pathological disease processes

Question 26

Using Maslow's Hierarchy of Needs,rank the following nursing diagnoses in order of importance,beginning with the highest-priority diagnosis.(Enter using the following format: 1,2,3,4)
1)Anxiety
2)Risk for infection
3)Disturbed body image
4)Sleep deprivation

Question 27

After identifying problems and etiologies and prior to writing a nursing diagnosis statement,the nurse would:

A) Verify the nursing diagnosis with the patient
B) Verify information with the primary care provider
C) Check the medical diagnosis for consistency in treatments
D) Review the data and the diagnosis with another nurse

Question 28

Which statement related to prioritizing patient problems is most accurate?

A) Nurses must resolve one problem before addressing another problem.
B) Nurses prioritize problems in order of urgency.
C) Actual problem always take priority over risk problems.
D) Nurses give the highest priority to problems that the patient thinks are most important.