Deck 4: Analysisdiagnosis

Question 1

The nurse is formulating a nursing diagnosis for a patient. Which definition most accurately describes nursing diagnoses?
1)Supports the nurse's diagnostic reasoning
2)Supports the client's medical diagnosis
3)Identifies a client's response to a health problem
4)Identifies a client's health problem

Answer 1

3

Question 2

The nurse is providing care for various patients in an acute care facility. Which patient issue is a problem that nurses can treat independently?
1)Hemorrhage following surgery
2)Nausea after ambulating in the hall
3)Fracture pain following an accident
4)Infection in a wound

Answer 2

2

Question 3

The nurse has diagnosed Decisional Conflict related to unclear personal values and beliefs, and the patient shows the necessary defining characteristics. Which essential action does the nurse take to help ensure the accuracy of this diagnosis?
1)Ask a more experienced nurse to confirm it
2)Request a social worker interview the patient
3)Ask for the patient's confirmation of the diagnosis
4)Read about Decisional Conflict in the NANDA-I handbook

Answer 3

3

Question 4

The nurse manager notices that a staff nurse writes a nursing diagnosis as "Impaired Physical Mobility, related to laziness and not having appropriate shoes." Which issue related to the nursing diagnosis will the nurse manager discuss with the staff nurse?
1)The staff nurse is being judgmental.
2)As written, the diagnosis is too complex.
3)The diagnosis is legally questionable.
4)There is deficiency of supportive data.

Question 5

Which of the following is an example of what the nurse recognizes as a cluster of related cues?
1)Complains of nausea and stomach pain after eating
2)Has a productive cough and states stools are loose
3)Has a daily bowel movement and eats a high-fiber diet
4)Has a respiratory rate of 20 breaths/min, heart rate of 85 beats/min, and blood pressure of 136/84 mm Hg

Question 6

A patient verbalizes an overwhelming lack of energy, stating, "I still feel exhausted even after sleeping. I feel guilty when I can't keep up with my usual daily activities, or I sleep during the day. I've been a little depressed lately, too." The nurse notes the patient's difficulty concentrating but does not note any apparent physical problems. Which diagnoses best describes the patient's health status?
1)Fatigue related to depression
2)Fatigue related to difficulty concentrating
3)Guilt related to lack of energy
4)Chronic confusion related to lack of energy

Question 7

Which nursing diagnosis is written in the correct format?
1)Imbalanced Nutrition: Less than Body Requirements, related to body weight less than 20% under ideal weight
2)Ineffective Airway Clearance, related to increased respiratory rate and irregular rhythm
3)Impaired Swallowing, related to absent gag reflex
4)Excess Fluid Volume, related to 3 lb weight gain in 24 hours

Question 8

The nurse has relocated to a different state and has accepted a position as a staff nurse on an acute care nursing unit. The patient care team consists of both registered nurses (RNs) and licensed practical nurses/licensed vocational nurses (LPNs/LVNs). Which action by the nurse constitutes a possible theoretical error?
1)Assigning an LPN/LVN to formulate a nursing diagnosis
2)Instructing an LPN/LVN to perform a prescribed dressing change
3)Delegating an RN to perform the admitting history on a new client
4)Expecting RNs and LPNs/LVNs to administer medications to assigned clients

Question 9

The nurse has gathered information about a client, has sorted the information, and is preparing to identify the diagnostic label, or patient problem. For which purpose are diagnostic labels primarily used?
1)To set client goals
2)To make cue clusters
3)To identify interventions
4)To understand disease etiology

Question 10

Which statement made by the nurse is an example of stereotyping?
1)"Patients with a Japanese background are always quiet and emotionless."
2)"Patients with type 1 diabetes do not make insulin and will need to take insulin regularly."
3)"The patient needs to understand the benefits of getting out of bed and not cry each time."
4)"I am confused why the client at 2 years of age is having a tantrum; my child never has one."

Question 11

The nurse is applying the nursing process to the development of a plan of care for a patient. Based on the patient's problems, the nurse is using Maslow's Hierarchy of Needs. Which nursing diagnosis does the nurse recognize as having the highest priority?
1)Self-Care Deficit
2)Risk for Aspiration
3)Impaired Physical Mobility
4)Functional Urinary Incontinence

Question 12

Which of the following is the best example of a nursing diagnosis statement?
1)Pain related to appendicitis
2)Fractured left leg related to impaired mobility
3)Impaired mobility related to fractured left leg
4)Acute pain related to out of bed activities

Question 13

Which nursing diagnosis is written in the correct format when using NANDA-I taxonomy?
1)Bowel Obstruction, related to recent abdominal surgery, as manifested by (AMB) nausea, vomiting, and abdominal pain
2)Inability to Ingest Food, related to imbalanced nutrition: less than body requirements, AMB inadequate food intake, weight less than 20% under ideal body weight
3)Impaired Skin Integrity, related to physical immobility, AMB skin tear over sacral area
4)Caregiver Role Strain, related to alienation from family and friends, AMB 24-hour care responsibilities

Question 14

The nurse works in an extended care facility. The residents are primarily older adults with health factors that put them in danger of falling. Which option best describes the type of nursing diagnosis the nurse is likely to use?
1)A risk diagnosis, because it is based on data about the patients
2)A possible diagnosis, because a suspected diagnosis is present
3)A wellness diagnosis, because of the health status and patient environment
4)A syndrome diagnosis, because of the age and physical condition of the patients

Question 15

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

Question 16

A staff nurse states, "I get tired of all the paperwork about nursing diagnosis and plans for patient care." Which of the following describes the most important purpose for developing a nursing diagnosis?
1)Differentiates the nurse's role from that of the physician
2)Identifies a body of knowledge unique to nursing
3)Helps nursing develop a more professional image
4)Describes the client's needs for nursing care

Question 17

A client's weight is appropriate for the client's height, and laboratory values and other assessments reflect normal nutritional status. However, the client states, "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 nursing diagnoses does the nurse use?
1)Balanced Nutrition
2)Possible Imbalanced Nutrition: Less Than Body Requirements
3)Risk for Imbalanced Nutrition: Less Than Body Requirements
4)Readiness for Enhanced Nutrition

Question 18

When making a diagnosis using NANDA-I taxonomy, which part of the statement provides support for the diagnostic label you choose?
1)Etiology
2)Related factors
3)Diagnostic label
4)Defining characteristics

Question 19

Which of the following describes the difference between a collaborative problem and a medical diagnosis?
1)A collaborative problem is treated by the nurse; a physician is responsible for the treatment of a medical problem.
2)A collaborative problem is a nursing diagnosis that requires specific orders from a physician; a medical diagnosis directs all nursing care.
3)A collaborative problem has the potential to become an actual nursing diagnosis; a medical diagnosis rarely changes.
4)A collaborative problem requires intervention by the nurse and the physician or other professional; a medical diagnosis requires intervention by a physician.

Question 20

The nurse is aware that which approach is best to validate a clinical inference?
1)Have another nurse evaluate it
2)Have the physician evaluate it
3)Have sufficient supportive data
4)Have the client's family confirm it

Question 21

The nurse completes assessment on a patient and begins to formulate a nursing diagnosis from the collected data. Which action does the nurse take prior to writing the nursing diagnosis statement?
1)Verifies the nursing diagnosis with the patient
2)Validates information with the primary care provider
3)Checks the medical diagnosis for consistency in treatments
4)Reviews the data and the diagnosis with another nurse

Question 22

The nurse receives reports on four patients on a medical-surgical unit. Which patient will the nurse attend to first?
1)Gait unsteady, uses walker, needs two-person assist with ambulation
2)Abdominal wound with foul-smelling drainage, incision margins are red, heart rate 100 beats/min
3)Blood pressure 90/50 mm Hg, heart rate 40 beats/min, patient rates chest pain at 8 on a 0-to-10 pain scale
4)Verbalizes history of migraine headaches, eyes closed during assessment interview

Question 23

The nurse is providing care for a patient following abdominal surgery. The nurse created a collaborative diagnosis of "Potential complication of surgery: hemorrhage" During patient assessment, the nurse recognizes the symptoms of serious blood loss. The nurse is aware that which action is now relative to the collaborative diagnosis?
1)The diagnosis is modified to watch for "continued" hemorrhage.
2)The diagnosis is removed because of the development of a medical problem.
3)The nurse collaborates with the physician to formulate a new diagnosis.
4)The nurse documents the effectiveness and value of the initial diagnosis.

Question 24

Which statements regarding nursing diagnoses are accurate? Select all that apply.
1)Provide the basis for nursing interventions
2)Are validated with patient and family, when possible
3)Have historically been well substantiated by research
4)Contain descriptions of pathological disease processes
5)Analyze assessment data by using critical-thinking skills

Question 25

Which statement related to the nurse prioritizing patient problems is most accurate?
1)Nurses must resolve one problem before addressing another problem.
2)Nurses prioritize problems in the order of problem urgency.
3)Nurses give priority to actual problems instead of risk problems.
4)Nurses give the highest priority to problems most important to the patient.

Question 26

The nurse manager is evaluating the nursing diagnoses written by staff nurses. Which nursing diagnosis statements does the nurse manager identify as being written correctly? Select all that apply.
1)Chronic Pain, related to osteoarthritis, as manifested by (AMB) patient rating pain at 8 on a 0 to 10 pain scale and having difficulty with ambulation
2)Ineffective Airway Clearance, related to excessive mucus, AMB cough, shortness of breath, change in respiratory rate and rhythm
3)Caregiver Role Strain, related to increasing care needs, AMB wife stating, "He is just getting too heavy for me to lift"
4)Anxiety (moderate), related to cardiac catheterization, AMB crying and yelling at family members
5)Emotional distress, AMB inability to eat related to recent diagnosis of a terminal disease

Question 27

What are the benefits for nursing practice in using a standardized nursing language when writing nursing diagnoses? Select all that apply.
1)Defines and communicates nursing knowledge
2)Assists the nurse in understanding medical diagnoses
3)Facilitates better understanding of nursing research
4)Helps nurses provide consistent interventions for all patients
5)Promotes medical understanding of nursing functions