Question 1

A nurse writes the following nursing diagnosis for a client with Alzheimer's disease: Disturbed Thought Processes related to Alzheimer's disease as evidenced by incoherent language. Which part of this diagnosis is considered the problem statement?

Accepted Answer

The problem statement in this nursing diagnosis is "disturbed thought processes."

Question 2

The nurse has drafted a nursing diagnosis of Imbalanced Nutrition: More Than Body Requirements in the care of moderately obese client. How should the nurse proceed after writing this diagnosis?

Accepted Answer

After writing a nursing diagnosis, the nurse should validate it to ensure it accurately reflects the client's condition and is supported by assessment data.

Question 3

A client with a new colostomy often becomes short and sarcastic when nurses attempt to teach him about the management of his new appliance. The nurse has consequently documented "Noncompliance related hostility" on the client's chart. What mistake has the nurse made when choosing and documenting this nursing diagnosis?

Accepted Answer

The nurse has presumed to know the factors contributing to the problem when choosing the nursing diagnosis "Noncompliance related hostility." The nurse has not assessed or explored the client's reasons for being short and sarcastic. This diagnosis also implies blame on the client, which could potentially damage the therapeutic relationship. A more appropriate diagnosis and documentation would be "Readiness for enhanced knowledge about colostomy care" or "Ineffective coping related to changes in body image and function."

Question 4

What is the focus of a diagnostic statement for a collaborative problem?

Accepted Answer

The focus of a diagnostic statement for a collaborative problem is on the potential complication that might arise, requiring both nursing and medical interventions to prevent or manage the problem.

Question 5

Which of the following statements accurately describes the legal responsibility of the nurse making a diagnosis for a client?

Accepted Answer

The nurse must assess if he or she is qualified to make a nursing diagnosis and take responsibility for treating it. Nursing diagnoses are not medical diagnoses and do not require physician involvement. The nurse practitioner may make nursing diagnoses, but so may any registered nurse who is appropriately trained and competent. The health care facility may use nursing diagnoses for billing purposes, but this does not direct the nursing diagnosis.

Question 6

A student is reviewing a client's chart before giving care. She notes the following diagnoses in the contents of the chart: "appendicitis" and "acute pain." Which of the diagnoses is a medical diagnosis?

Accepted Answer

Appendicitis is a medical diagnosis, while acute pain is a symptom.

Question 7

In planning the care for a client who has pneumonia, the nurse collects data and develops nursing diagnoses. Which of the following is an example of a properly developed nursing diagnosis?

Accepted Answer

A properly developed nursing diagnosis includes a problem (ineffective airway clearance) and evidence or defining characteristics (inability to clear secretions). The other options do not have evidence or defining characteristics to support the nursing diagnosis.

Question 8

A nurse is reviewing the health history and physical assessment findings for a client who is having respiratory problems. Of the following data collected, what data from the health history would be a cue to a nursing diagnosis for this problem?

Accepted Answer

Getting out of breath when walking a few steps is a cue for respiratory problems, which could potentially lead to a nursing diagnosis for impaired gas exchange or ineffective breathing pattern. Options A, B, and D do not relate to respiratory problems.

Question 9

Which of the following client care concerns is clearly a nursing responsibility?

Accepted Answer

Monitoring health status changes is clearly a nursing responsibility as it falls under the scope of nursing practice to assess and monitor the client's health status and report any changes to other healthcare professionals. Prescribing medications and performing surgical procedures are not within a nurse's scope of practice, and ordering diagnostic examinations may be done by a nurse practitioner or physician but not necessarily a registered nurse.

Question 10

A nurse completes a health history and physical assessment for an adolescent before he begins football practice. Based on findings, the nurse recommends reinforcing good health habits. What conclusion did the nurse reach after interpreting and analyzing the data?

Accepted Answer

The nurse's recommendation to reinforce good health habits suggests that there were no immediate health concerns identified during the health history and physical assessment, indicating no problem was found.

Question 11

Successful implementation of each step of the nursing process requires high-level skills in critical thinking. Which of the following statements accurately describe a guideline for using this process?

Accepted Answer

Keeping an open mind and trusting your intuition are important aspects of critical thinking in nursing, allowing for comprehensive and accurate diagnoses.

Question 12

After completing assessments, a nurse uses the data collected to identify appropriate nursing diagnoses for a client. For what are the nursing diagnoses used?

Accepted Answer

Nursing diagnoses are used to select appropriate nursing interventions to meet expected outcomes for the client. Once a nursing diagnosis has been identified, it can guide the development of a plan of care that includes interventions aimed at addressing the client's specific health care needs. By addressing these needs, nursing interventions are expected to improve the client's health outcomes.

Question 13

A nurse caring for an older adult client in a long-term care facility notices that the bedding is wet when the client gets up in the morning. The nurse collects more data to form a conclusion. What type of problem is involved in this scenario?

Accepted Answer

The scenario suggests a possible problem because the wet bedding indicates that there might be an issue (such as incontinence), but further assessment is needed to confirm and understand the problem fully.

Question 14

Which of the following is a correct guideline to follow when composing a nursing diagnosis statement?

Accepted Answer

The correct guideline is to place defining characteristics after the etiology and link them by the phrase "as evidenced by," which helps in clearly identifying the signs and symptoms that support the diagnosis.

Question 15

A nurse is formulating a nursing diagnosis for a client with a respiratory disease. Which of the following would be correct?

Accepted Answer

The nursing diagnosis should be based on the patient's actual or potential health problems, and should be formulated with a problem, etiology, and symptoms. In this case, "ineffective airway clearance" is the problem, "related to thick mucus" is the etiology, and the symptom would be the patient's difficulty breathing or other respiratory-related symptoms. Option A is incorrect because it is not a nursing diagnosis, but rather an intervention. Option B is almost correct, but it is missing the etiology (i.e., related to thick mucus). Option D is incorrect because it is a behavior and not a diagnostic statement.

Question 16

A nurse develops a plan of care to meet the needs of a client who has had a large loss of blood after a snowmobile crash. Intravenous fluids and blood are administered and the nurse monitors the client's physiologic response. This action is known as a:

Accepted Answer

Collaborative problems are potential complications that nurses manage using both physician-prescribed and nursing-prescribed interventions to minimize the complications of events such as a large loss of blood.

Question 17

The nurse has identified a number of risk nursing diagnoses in the care of an adolescent who has been admitted to the hospital for treatment of an eating disorder. These risk diagnoses indicate which of the following?

Accepted Answer

Risk nursing diagnoses indicate that the client is more vulnerable to certain problems than other individuals would be. These diagnoses do not necessarily indicate the presence of a medical diagnosis or the absence of necessary data for a definitive nursing diagnosis.

Question 18

A nurse observes a new mother tenderly holding and softly talking to her baby. What does this observation tell the nurse about the baby's strengths?

Accepted Answer

The observation of the mother holding and talking softly to her baby indicates that nurturing is a strength for developing infants. This suggests that the baby may benefit from a supportive and caring environment that promotes healthy emotional and social development.

Question 19

In addition to identifying responses to actual or potential health problems, what is another purpose of the diagnosing step in the nursing process?

Accepted Answer

The diagnosing step in the nursing process also involves identifying the etiologies or causes of health problems, which helps in planning appropriate interventions.

Question 20

Which of the following provides the nurse with the most reliable basis on which to choose a nursing diagnosis?

Accepted Answer

A cluster of several significant cues of data that suggest a particular health problem provides the nurse with the most reliable basis on which to choose a nursing diagnosis as it considers several cues instead of relying on a single cue or objective medical data alone. Additionally, a group of related nursing diagnoses within the same NANDA-approved domain may provide helpful guidance, but it is not always necessary or sufficient for choosing a nursing diagnosis.

Quiz 12: Diagnosing