Question 1

A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?

A) Risk
B) Problem focused
C) Health promotion
D) Collaborative problem

Health promotion

Accepted Answer

A health promotion nursing diagnosis is a clinical judgment concerning motivation and desire to increase well-being and actualize human health potential. A problem-focused nursing diagnosis describes a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, or community. A risk nursing diagnosis is a clinical judgment concerning the vulnerability of an individual, family, group or community for developing an undesirable human response to health conditions/life processes. A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's health status.

Question 2

A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing?&#10;A) Assigning clinical cues&#10;B) Defining characteristics&#10;C) Diagnostic reasoning&#10;D) Diagnostic labeling

Accepted Answer

Diagnostic reasoning is defined as a process of using the assessment data gathered about a patient to logically explain a clinical judgment, in this case a nursing diagnosis. Defining characteristics are assessment findings that support the nursing diagnosis. Defining characteristics are the subjective and objective clinical cues, which a nurse gathers intentionally and unintentionally. The nurse organizes all of the patient's data into meaningful and usable data clusters, which lead to a diagnostic conclusion. Diagnostic labeling is simply the name of the diagnosis.

Question 3

A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge nurse to follow up?&#10;A) Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous (IV) antibiotics&#10;B) Completing an interview and physical examination before adding a nursing diagnosis&#10;C) Developing nursing diagnoses before completing the database&#10;D) Including cultural and religious preferences in the database

Accepted Answer

Developing nursing diagnoses before completion of the database needs to be corrected by the charge nurse. Always identify a nursing diagnosis from the data, not the reverse. The data should be clustered and reviewed to see if any patterns are present before a nursing diagnosis is assigned. Risk for infection is an appropriate diagnosis for a patient with an intravenous (IV) site in place. The IV site involves a break in skin integrity and is a potential source of infection. The diagnostic process should proceed in steps. Completing the interview and physical examination before adding a nursing diagnosis is appropriate. The patient's cultural background and developmental stage are important to include in a patient database.

Question 4

A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?&#10;A) Ineffective breathing pattern related to pneumonia&#10;B) Risk for infection related to chest x-ray procedure&#10;C) Risk for deficient fluid volume related to dehydration&#10;D) Impaired gas exchange related to alveolar-capillary membrane changes

Accepted Answer

The related to factor of alveolar-capillary membrane changes is accurately written because it is a patient response to the disease process of pneumonia that the nurse can treat. The related to factor should be the cause of the problem (nursing diagnosis) that a nurse can address. The related to factors of dehydration and pneumonia are all medical diagnoses that the nurse cannot change. A diagnostic test or a chronic dysfunction is not an etiology or a condition that a nursing intervention is able to treat.

Question 5

A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to the patient's care plan?&#10;A) Infection&#10;B) Risk for infection&#10;C) Impaired skin integrity&#10;D) Staphylococcal leg infection

Accepted Answer

Impaired skin integrity is the only nursing diagnosis listed that will correlate to the patient information. While risk for infection is a nursing diagnosis, the patient is not at risk; the patient has an actual infection. Infection can be a medical diagnosis as well as a collaborative problem. Staphylococcal leg infection is a medical diagnosis.

Question 6

After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse's actions?&#10;A) To form a language that can be encoded only by nurses&#10;B) To distinguish the nurse's role from the physician's role&#10;C) To develop clinical judgment based on other's intuition&#10;D) To help nurses focus on the scope of medical practice

Accepted Answer

The standard formal nursing diagnosis serves several purposes. Nursing diagnoses distinguish the nurse's role from that of the physician/health care provider and help nurses focus on the scope of nursing practice (not medical) while fostering the development of nursing knowledge. A nursing diagnosis provides the precise definition that gives all members of the health care team a common language for understanding the patient's needs. A diagnosis is a clinical judgment based on information.

Question 7

A new nurse writes the following nursing diagnoses on a patient's care plan. Which nursing diagnosis will cause the nurse manager to intervene?&#10;A) Wandering&#10;B) Hemorrhage&#10;C) Urinary retention&#10;D) Impaired swallowing

Accepted Answer

Hemorrhage is a collaborative problem, not a nursing diagnosis; the nurse manager will need to correct this misunderstanding with the new nurse. Nurses manage collaborative problems such as hemorrhage, infection, and paralysis using medical, nursing, and allied health (e.g., physical therapy) interventions. Wandering, urinary retention, and impaired swallowing are all examples of nursing diagnoses.

Question 8

A nurse performs an assessment on a patient. Which assessment data will the nurse use as an etiology for Acute pain?&#10;A) Discomfort while changing position&#10;B) Reports pain as a 7 on a 0 to 10 scale&#10;C) Disruption of tissue integrity&#10;D) Dull headache

Accepted Answer

Disruption of tissue integrity is a possible cause or etiology of pain. A report of pain, headache, and discomfort are examples of things a patient might say (subjective data or defining characteristics) that may lead a nurse to select Acute pain as a nursing diagnosis.

Question 9

A nurse is developing nursing diagnoses for a patient. Beginning with the first step, place in order the steps the nurse will use.
1) Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma
2) Writes a diagnostic label of impaired gas exchange
3) Organizes data into meaningful clusters
4) Interprets information from patient
5) Writes an etiology

A) 1, 3, 4, 2, 5
B) 1, 3, 4, 5, 2
C) 1, 4, 3, 5, 2
D) 1, 4, 3, 2, 5

Accepted Answer

The diagnostic process flows from the assessment process (observing and gathering data) and includes decision-making steps. These steps include data clustering, identifying patient health problems, and formulating the diagnosis (diagnosis is written as problem or NANDA-I approved diagnosis then etiology or cause).

Question 10

A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention?&#10;A) &#34;Do you feel like you need to go to the bathroom?&#34;&#10;B) &#34;Are you able to walk to the bathroom by yourself?&#34;&#10;C) &#34;When was the last time you took your medicine?&#34;&#10;D) &#34;Do you have a safety rail in your bathroom at home?&#34;

Accepted Answer

The nurse must establish that the patient feels the urge and is unable to void. The question "Do you feel like you need to go to the bathroom?" is the most appropriate to ask. This question can be ansed without knowledge of the diagnosis of Urinary retention. Discussing the ability to walk to the bathroom and asking about safety rails pertain to mobility and safety issues, not to retention of urine. Taking certain medications may lead to urinary retention, but that information would establish the etiology. The question is asking for the nurse to first establish the correct diagnosis.

Question 11

A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?

A) Posttrauma syndrome
B) Constipation
C) Acute pain
D) Anxiety

Accepted Answer

The answer of A patient presents to the emergency department...

Question 12

A nurse adds the following diagnosis to a patient's care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic?

A) Decreased gastrointestinal motility
B) Pain medication
C) Abdominal distention
D) Constipation

Accepted Answer

The answer of A nurse adds the following diagnosis to...

Question 13

A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. The nurse analyzes the data. Which nursing diagnosis will the nurse assign to the patient?

A) Adult failure to thrive
B) Hypothermia
C) Deficient fluid volume
D) Nausea

Accepted Answer

The answer of A patient exhibits the following symptoms: tachycardia,...

Question 14

A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse document?&#10;A) Decreased cardiac output related to altered myocardial contractility.&#10;B) Patient needs a low-fat diet related to inadequate heart perfusion.&#10;C) Offer a low-fat diet because of heart problems.&#10;D) Acute heart pain related to discomfort.

Accepted Answer

The answer of A nurse adds a nursing diagnosis to...

Question 15

The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, reports of shortness of breath when getting out of bed, and a productive cough. Which elements will the nurse identify as defining characteristics for the diagnostic label of Activity intolerance?

A) Decreased oral intake and decreased oxygen saturation when ambulating
B) Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed
C) Reports of shortness of breath when getting out of bed and a productive cough
D) Productive cough and decreased oral intake

Accepted Answer

The answer of The patient database reveals that a patient...

Question 16

The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?

A) Etiology
B) Nursing diagnosis
C) Collaborative problem
D) Defining characteristic

Accepted Answer

The answer of The nurse is reviewing a patient's plan...

Question 17

A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error?

A) Assessment
B) Diagnosis
C) Implementation
D) Evaluation

Accepted Answer

The answer of A nurse administers an antihypertensive medication to...

Question 18

Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved?&#10;A) Sore throat&#10;B) Acute pain&#10;C) Sleep apnea&#10;D) Heart failure

Accepted Answer

The answer of Which diagnosis will the nurse document in...

Question 19

The nurse is reviewing a patient's database for significant changes and discovers that the patient has not voided in over 8 hours. The patient's kidney function lab results are abnormal, and the patient's oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?

A) Diagnosis
B) Planning
C) Implementation
D) Evaluation

Accepted Answer

The answer of The nurse is reviewing a patient's database...

Question 20

Which question would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea?&#10;A) &#34;What types of foods do you think caused your upset stomach?&#34;&#10;B) &#34;How many bowel movements a day have you had?&#34;&#10;C) &#34;Are you able to get to the bathroom in time?&#34;&#10;D) &#34;What medications are you currently taking?&#34;

Accepted Answer

The answer of Which question would be most appropriate for...

Question 21

A nurse is developing nursing diagnoses for a patient. Beginning with the first step, place in order the steps the nurse will use.
1) Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma
2) Writes a diagnostic label of impaired gas exchange
3) Organizes data into meaningful clusters
4) Interprets information from patient
5) Writes an etiology

A) 1, 3, 4, 2, 5
B) 1, 3, 4, 5, 2
C) 1, 4, 3, 5, 2
D) 1, 4, 3, 2, 5

Accepted Answer

The answer of A nurse is developing nursing diagnoses for...

Deck 17: Nursing Diagnosis