Deck 7: Nursing Diagnosis

Question 1

A patient is receiving an experimental drug for leukemia. The nurse is worried that the drug may cause a reduction in platelets leading to intestinal tract bleeding. Which type of nursing diagnosis should the nurse use to address this concern?

A) Risk
B) Actual
C) Health-promotion
D) Medical diagnosis

Answer 1

Risk

Question 2

The nurse in an outpatient clinic obtains a blood pressure of 190/88 mm Hg on a patient diagnosed with high blood pressure. The patient tells the nurse, "My blood pressure medicine is really expensive. Do you think I really need it?" The nurse assumes the patient is not taking the medication based on the blood pressure result and the patient's statement and chooses noncompliance as a diagnostic label. The action by the nurse is an example of:

A) clustering unrelated data in the diagnostic statement.
B) selecting erroneous data for use in the diagnostic statement.
C) using medical diagnoses in the diagnostic statement.
D) identifying multiple problems within one diagnostic statement.

Answer 2

clustering unrelated data in the diagnostic statement.

Question 3

The nurse is reviewing data obtained through the health history interview and physical assessment of an assigned patient. Data collected include dry skin, brittle nails, weight gain, thinning hair, constipation, prolonged menstruation, and the patient's complaints of feeling tired and cold. Which statement represents an appropriate data cluster?

A) Prolonged menstruation, constipation
B) Dry skin, brittle nails, weight gain
C) Tired, cold, thinning hair
D) Constipation, weight gain

Answer 3

Constipation, weight gain

Question 4

The nurse is caring for a patient diagnosed with blood clots in the right lower extremity. The admitting physician orders bed rest. The patient tells the nurse, "I usually exercise three times a week. It helps me go to the bathroom." The nurse determines that the patient may have difficulty with bowel movements. Which nursing diagnosis statement accurately reflects the nurse's concern?

A) Constipation related to bed rest as manifested by hard, dry stools.
B) Perceived constipation resulting from patient's expectation manifested by patient statement.
C) Risk for constipation related to immobility as manifested by verbal complaint.
D) Risk for constipation related to insufficient physical activity.

Question 5

The nurse is developing a plan of care for a patient who has had a stroke. Assessment findings include weakness in right upper and lower extremities, numbness in face, slurred speech, and headache. Which of the following would best represent the etiology of the patient's gait and balance problems?

A) Lack of muscle motor movement
B) Decreased sensation to touch
C) Inability to speak clearly
D) Pain in back of head

Question 6

A nurse completes a care plan for an assigned patient diagnosed with an inflammation of the pericardium. Which diagnosis written on the plan indicates a need for further instruction on using the nursing process?

A) Pericarditis
B) Acute pain
C) Risk for decreased cardiac output
D) Activity intolerance

Question 7

The nursing student is reviewing the components of a nursing diagnosis. Which statement made by the student indicates correct understanding of a health-promotion diagnostic statement?

A) "The defining characteristics will include the patient's willingness to get better."
B) "The risk factors are only psychological in nature, not physical."
C) "The health-promotion diagnostic statement is composed of three parts."
D) "An example of a health-promotion label is ineffective community coping."

Question 8

The nurse is caring for a Vietnamese-American admitted to the intensive care unit as a result of malnutrition. The patient is unable to walk because of his malnutrition, and he has developed a pressure ulcer from lying in bed constantly without changing positions. The family believes that the patient is depressed and that is why he stopped getting up. When planning this patient's care, the nurse should:

A) develop multiple nursing diagnoses.
B) develop only one nursing diagnosis to aid in focusing.
C) focus on the physical issues facing this patient.
D) deal primarily with the patient's psychological needs.

Question 9

The nurse is developing a plan of care for a patient with gastritis and an inflammation of the intestines. The patient is complaining of severe abdominal discomfort and nausea. The patient also reports having restless leg syndrome and an inability to urinate. As a problem statement of the nursing diagnosis, the nurse should write:

A) Gastritis related to inflammation.
B) Alterations in comfort and ability to void.
C) Abdominal pain and nausea related to inflammation.
D) Alteration in comfort related to restless leg syndrome and inflammation.

Question 10

The nursing student submits a care plan to the nursing instructor for a review prior to implementing the nursing interventions. Which of the following nursing diagnostic statements is written incorrectly?

A) Ineffective coping related to inadequate support systems as evidenced by patient's verbalization, "I don't have any friends or family in town. I just moved here a week ago."
B) Activity intolerance related to immobility as manifested by shortness of breath and patient's verbalization of fatigue.
C) Insomnia and knowledge deficit related to stress as evidenced by patient report of difficulty sleeping and lack of energy.
D) Self-care deficit bathing related to upper extremity weakness as manifested by inability to wash body.

Question 11

Nursing students are analyzing the following nursing diagnostic statement during a study group session. Acute pain related to pressure on lumbar spinal nerves as evidenced by a pain level of 9, patient verbalizations of pain, and grimacing when walking. The students would be correct if they stated that the etiology of the patient's problem is:

A) patient verbalizations of pain.
B) acute pain.
C) pressure on lumbar spinal nerves.
D) grimacing when walking.

Question 12

The nurse is admitting a patient with severe dehydration. Assessment data reveal a decreased blood pressure, an increased pulse rate, and a low circulating blood volume. The student observes that the patient is confused and restless. Which patient information would the nurse consider as a contributing factor when choosing the nursing diagnostic label?

A) Blood pressure, pulse rate
B) Blood pressure, pulse rate, blood volume
C) Blood pressure, pulse rate, blood volume, mental status
D) Blood pressure, pulse rate, blood volume, mental status, dehydration

Question 13

The nurse is reviewing assessment findings on a patient admitted with an extremely slow heart rate. The patient complains of dizziness, shortness of breath, chest pain, and fainting spells. Vital signs are blood pressure of 98/60 mm Hg and pulse of 52 beats/minute. Oxygen saturation is 88%. Which action should the nurse perform next?

A) Exclude all subjective data in favor of objective data.
B) Focus on data gathered during the physical assessment.
C) Evaluate the data looking for patterns and related data.
D) Dismiss family members input as "hearsay."

Question 14

The nurse completes a health and physical assessment on a patient admitted with a fractured pelvis. Which of the following tasks should the nurse do next?

A) Analyze and cluster the assessment information.
B) Formulate a nursing diagnosis addressing actual issues.
C) Determine the need for potential nursing diagnoses.
D) Create health promotion diagnoses for the patient.

Question 15

When creating a nursing diagnosis, the related factor:

A) should be based on the medical diagnosis.
B) in unrelated to the pathophysiology with which the patient is dealing.
C) is the underlying etiology of the patient's situation.
D) does not reflect the nurse's understanding of pathophysiology.

Question 16

The nurse has identified several problems for a patient scheduled for a bone marrow transplant. By formulation of nursing diagnoses, the nurse:

A) embraces "cook book medicine" and rejects professional autonomy.
B) uses a language that is difficult to interpret by legislators.
C) is able to communicate with other nurses but not other disciplines.
D) facilitates communication of patient needs and promotes accountability.

Question 17

A group of patients in a community center attend a nursing-led information session on the risks of contracting tuberculosis. After the presentation several patients ask the nurse for additional web-based resources regarding the lung disease. Which type of nursing diagnosis would the nurse choose for the community care plan?

A) Risk
B) Actual
C) Health-promotion
D) Potential

Question 18

North American Nursing Diagnosis Association International (NANDA-I) is an organization focusing on revising nursing diagnosis taxonomy and evaluates nursing research to validate the diagnostic labels. The NANDA-I taxonomy and new nursing diagnoses are published every:

A) 2 years.
B) 3 years.
C) 4 years.
D) 5 years.

Question 19

The nurse is writing the care plan for a patient admitted to the hospital for complications associated with muscular dystrophy. Which nursing diagnoses written on the care plan indicate a need for further instruction in constructing the diagnostic statement?

A) Constipation related to immobility as manifested by lower extremity weakness.
B) Activity intolerance related to weakness as evidenced by verbal report of fatigue.
C) Feeding self-care deficit related to fatigue as manifested by inability to swallow food.
D) Ineffective airway clearance related to muscle weakness.

Question 20

The nurse is caring for a complex patient needing physical and emotional support. As the primary care giver, the nurse:

A) is ultimately responsible for assessment of patient needs and progress.
B) delegates to people who know what they are doing and operate independently.
C) provides total care to the patient after getting direction from other disciplines.
D) understands that the patient is ultimately responsible for failure or success.

Question 21

The nurse is caring for a patient admitted to the psychiatric unit as a result of an overdose of cocaine. Which nursing diagnosis indicates an understanding of a nursing diagnostic statement? (Select all that apply.)

A) Ineffective breathing pattern related to drug effect on the respiratory center
B) Risk for injury related to hallucinations
C) Insomnia
D) Chronic confusion related to excessive stimulation of nervous system as evidenced by impaired socialization
E) Personality conflict

Question 22

The nurse has requested an order to place a patient on suicide watch. Which data noted in the health assessment led the nurse to this conclusion? (Select all that apply.)

A) Threats of killing oneself
B) Chronic pain
C) History of prior suicide attempt
D) Loneliness
E) Stable heart rhythm

Question 23

The nurse is creating a care plan for a patient admitted with severe bone pain related to an infected leg wound. Which diagnosis written on the plan indicates an understanding of the components of a nursing diagnosis? (Select all that apply.)

A) Acute pain
B) Risk for impaired walking
C) Ineffective bone tissue perfusion
D) Osteomyelitis
E) Infection

Question 24

A patient is admitted to the emergency room after experiencing severe chest pain and difficulty in taking deep breaths. The patient anxiously tells the nurse, "My father died suddenly of a heart attack at the age of 52. I'm so scared." Which nursing diagnoses are appropriate for this situation? (Select all that apply.)

A) Acute pain
B) Fear
C) Risk for aspiration
D) Risk for infection

Question 25

A group of nursing students is discussing the importance of accurately selecting nursing diagnoses. Which of the following are reasons for choosing the diagnoses carefully? (Select all that apply.)

A) Patient satisfaction
B) Positive patient outcomes
C) Quality patient care
D) Help develop standardized care plans
E) Determine appropriate interventions