Deck 13: Diagnosing

Question 1

An example of a qualifier within a nursing diagnosis is all of the following except:

A) decreased.
B) ineffective.
C) specific.
D) compromised.

Answer 1

specific.

Question 2

Aetiologies are an important part of nursing diagnosis because:

A) each may require different interventions.
B) a client's history helps to assess.
C) it provides a common label.
D) they provide objective data.

Answer 2

each may require different interventions.

Question 3

The nurse is reviewing the client's care plan and checking the quality of the nursing diagnosis statements. Criteria to use for guidelines in formulating nursing diagnoses include all of the following except:

A) non-judgmental statements.
B) must be legally advisable.
C) stated in terms of a described need.
D) cause/effect are correctly stated.

Answer 3

stated in terms of a described need.

Question 4

The nurse is preparing a care plan for a newly admitted client. The nurse is aware that an actual nursing diagnosis is used when:

A) there is the presence of associated signs and symptoms.
B) the problem has the potential to develop unless a nurse intervenes appropriately.
C) the medical diagnosis is used as a part of the diagnosis.
D) the nurse's clinical judgment indicates that there is a potential for a specific problem to arise in the client.

Question 5

The nurse has completed the initial assessment of a client and has analysed and clustered the data. The nurse's next step in the diagnostic process is to:

A) formulate a diagnosis.
B) research collaborative and nursing-related interventions.
C) verify the data.
D) identify the gaps and inconsistencies in data collected.

Question 6

A 2-year-old has been admitted to the paediatric unit with a two-day history of vomiting and diarrhoea. Which of the following would be a cue the nurse identifies as being outside the normal standard?

A) The child is able to hold finger foods.
B) The child has not attempted to speak.
C) The child's weight is 10kg.
D) The child cries when parents leave the room.

Question 7

The student nurse is learning about the components of a nursing diagnosis. Which statement by the student indicates a need for further instruction?

A) "An actual nursing diagnosis will have three components: the problem, the aetiology and the defining characteristics."
B) "An actual nursing diagnosis will include the medical diagnosis in the aetiology of the problem."
C) "A risk for nursing diagnosis will have two components: the problem and the aetiology."
D) "The defining characteristics are just the client's signs and symptoms that support the nursing diagnosis."

Question 8

A client who has just been diagnosed with pancreatic cancer is quite upset and verbal. The nurse has formulated the following diagnosis: Anxiety, related to unfamiliarity of disease process, manifested by restlessness and tachycardia. The aetiology of this diagnosis is which of the following?

A) Anxiety.
B) Restlessness.
C) Unfamiliarity of disease process.
D) Tachycardia.

Question 9

A client has been having pain without any clear pathology for the cause. The X-rays are normal, the client did not have an injury or fall, and there has been no recent trauma. The most appropriately written nursing diagnosis for this client would be which of the following?

A) Pain caused by psychosomatic condition.
B) Pain due to unknown factors.
C) Pain manifested by client's report.
D) Pain related to unknown aetiology.

Question 10

"Cue clustering" helps the nurse to determine:

A) if the clinical data varies from the norms of the population.
B) the relatedness of the data and determine whether any pattern in the cues are present.
C) if there is a development delay in the client.
D) if there are positive or negative changes in a person's health status.

Question 11

Accurately written nursing diagnoses do not include:

A) nursing terminology.
B) medical terminology.
C) non-judgmental statements.
D) patient needs.

Question 12

A nursing student is learning the application of the nursing process to client care. When questioned by the student about the reason for implementing a nursing diagnosis, the nursing professor responds: "The nursing diagnosis statement:

A) helps standardise care for all clients."
B) helps other health care professionals understand the plan of care."
C) describes client problems that nurses are educated and licensed to treat."
D) includes the disease the client has during the treatment of care."

Question 13

The student nurse understands that clustering data comes with experience and recognising cues. The best way for this student to recognise patterns or cues in the data is to:

A) work with seasoned and experienced nurses and learn from them.
B) depend on knowledge gained from peers' experiences.
C) know that this will take time, and experience is the best teacher.
D) take assessment notes and utilise information from reliable resources for comparison.

Question 14

Nursing diagnoses are different from medical diagnoses and collaborative problems in all of the following except:

A) orientation.
B) philosophy.
C) nursing focus.
D) duration.

Question 15

A client who has just been diagnosed with cancer is quite upset and anxious. The nurse has formulated the following diagnosis: Anxiety, related to unfamiliarity of disease process, manifested by restlessness and tachycardia. This diagnosis is which of the following?

A) Nursing diagnosis.
B) Medical diagnosis.
C) Collaborative problem.
D) Judgmental.

Question 16

A client is diagnosed with pneumonia and has been hospitalised for several days. A priority nursing diagnosis for this client is which of the following?

A) Altered oral mucous membranes, related to dry mouth.
B) Activity intolerance, related to oxygen supply imbalance.
C) Ineffective airway clearance, related to increased secretions.
D) Knowledge deficit, related to medication regimen.

Question 17

A client who has been in a wheelchair for several years is currently experiencing problems with skin breakdown and urinary retention. When formulating a nursing diagnosis, which of the following would be an appropriate selection?

A) Syndrome diagnosis.
B) Actual diagnosis.
C) Wellness diagnosis.
D) Risk nursing diagnosis.

Question 18

A client has been admitted to the cardiac intensive care unit following an acute myocardial infarction. The nurse formulates the following nursing diagnosis: Acute pain, related to tissue damage, secondary to infarction, manifested by pallor, client report, and shallow, rapid breathing. Which of the following would be an example of a collaborative intervention?

A) Administer pain medication.
B) Educate the client and family regarding treatment and therapies.
C) Monitor for changes in the client's condition.
D) Provide a calm, quiet atmosphere in the client's room.

Question 19

The nurse has formulated the following diagnosis: Activity intolerance, related to weakness and debilitation, manifested by reports of fatigue after any physical activity. What is the defining characteristic of this label?

A) Activity intolerance.
B) Reports of fatigue.
C) Physical activity.
D) Weakness and debilitation.

Question 20

Which of the following identifies the aetiology component of a nursing diagnosis?

A) Evidence of a health problem is incomplete and unclear.
B) Provides the nurse with minimal direction to the required nursing therapy.
C) There is one or more probable causes of the health problem.
D) Enables the nurse to generalise the care needed by the client.

Question 21

An experienced nurse has just walked into the room of a client to whom the nurse has been assigned for the shift. Which of the following might be a significant cue point to a change in the client's health status?

A) The client's eyes are closed.
B) The TV is on and the volume is turned up.
C) The client's spouse is asleep in the chair next to the bed.
D) The client's skin is pale and mottled.

Question 22

The nurse, after formulating several diagnoses for a client, does not understand the reason for some of the discrepancies in the client's lab values and diagnostic tests, when comparing to norms and standards. Which of the following is the best action of the nurse?

A) Verify the information with the client.
B) Consult other professionals and colleagues for clarification.
C) Compare all findings to the national norms and standards.
D) Improve critical-thinking skills so answers come more easily.

Question 23

The nurse has formulated a nursing diagnosis of, "Impaired skin integrity related to poor hygienic practice, secondary to current living conditions". Which of the following data would support this diagnosis?

A) Skin is dry, cracked.
B) Client does not drive.
C) Client states that they do not use alcohol or drugs.
D) Clothes are thin and untidy.

Question 24

A nurse is reviewing the problem list he has compiled with a client and the client's family. The nurse is also relating the various diagnoses he has formulated to this client, then asking for input from the client and family. The nurse is utilising which of the following to minimise diagnostic error?

A) Consulting resources.
B) Verifying.
C) Basing diagnoses on patterns.
D) Understanding what is normal versus what is not normal.

Question 25

A client just had a baby following a long labour and difficult delivery. Which of the following nursing diagnoses is formulated correctly?

A) Reduced urinary elimination, secondary to childbirth.
B) Reluctant to breast feed, related to lack of motivation, secondary to exhaustion.
C) Constipation, due to tissue trauma, manifested by no bowel movement for two days.
D) Risk for severe infection, because of new incision, related to episiotomy.

Question 26

A diagnostic statement:

A) needs to be descriptive and specific.
B) does not need to be validated with the client.
C) must be accurate, concise, descriptive and specific.
D) does not need to be checked against the NANDA-I criteria.