Deck 12: Diagnosing

Question 1

The nurse formulates the nursing diagnosis: Acute pain,related to tissue damage,secondary to infarction,manifested by pallor,client report,and shallow,rapid breathing for a client experiencing an acute myocardial infarction.Which collaborative action would be appropriate for this client?

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

Answer 1

Administer pain medication.

Question 2

The nurse is formulating a nursing diagnosis for a client with a long,extensive history of psychiatric problems,beginning in childhood,who is being placed in a long-term,structured institutional environment.Which diagnosis indicates the client's problem is adequately described?

A)Chronic low self-esteem,related to factors too numerous to mention
B)Risk for self-harm,related to many psychiatric problems
C)Impaired social interaction,due to long history of institutionalization
D)Alteration in thought processes,related to complex factors

Answer 2

Alteration in thought processes,related to complex factors

Question 3

An experienced nurse has just walked into the room of a newly assigned client.Which observation should the nurse use to include a new nursing diagnosis in this client's plan of care?

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

Answer 3

The client's skin is pale and mottled.

Question 4

A client has been having pain without any clear pathology for cause.Which nursing diagnosis should the nurse identify as being the most appropriate for this client?

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

Question 5

The nurse has formulated a diagnosis of Activity intolerance related to decreased airway capacity for a client with chronic asthma.In looking at the client's coping skills,the nurse realizes that the client has a vast knowledge about the disease and what exacerbates symptoms in particular situations.Why should the nurse utilize this information?

A)Strengths can be an aid to mobilizing health and the healing process.
B)The client will be more active in the plan.
C)It will be easier for the nurse to educate the client about other interventions.
D)The nurse won't have to spend time going over the pathology of the client's disease.

Question 6

After communicating with the client and family,the nurse compares a client's problem list with identified nursing diagnoses.What action is the nurse performing to minimize diagnostic errors?

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

Question 7

The nurse is caring for a client recovering from a long and difficult childbirth experience.Which nursing diagnosis did the nurse write appropriately for this client?

A)Constipation,due to tissue trauma,manifested by no bowel movement for 2 days
B)Risk for infection,because of new incision,related to episiotomy
C)Ineffective breast-feeding,related to lack of motivation,secondary to exhaustion
D)Altered urinary elimination,secondary to childbirth

Question 8

The graduate nurse is struggling with identifying cues from clustered data.What should the nurse use to recognize data patterns and cues?

A)Depend on knowledge gained from peers' experiences.
B)Work with seasoned and experienced nurses and learn from them.
C)Take assessment notes and utilize information from textbooks for comparison.
D)Know that this will take time,and experience is the best teacher.

Question 9

The nurse has completed the initial assessment of a client and has analyzed and clustered the data.What should the nurse complete next in the diagnostic process?

A)Formulate a diagnosis.
B)Verify the data.
C)Research collaborative and nursing-related interventions.
D)Identify the client's problem,health risks,and strengths.

Question 10

After formulating several diagnoses,the nurse 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 action should the nurse take?

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

Question 11

The nurse wants to propose a new nursing diagnosis.What action should the nurse take first?

A)Using the proposed nursing diagnosis when constructing client care plans
B)Getting permission for the proposed nursing diagnosis to be implemented by a nursing facility
C)Submitting the diagnosis to NANDA's Diagnostic Review Committee
D)Presenting the proposed nursing diagnosis at the local AMA (American Medical Association)meeting.

Question 12

A client is diagnosed with pneumonia and has been hospitalized for several days.Which nursing diagnosis should the nurse identify as a priority for this client?

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

Question 13

The nurse is reviewing information about the formulation of nursing diagnoses.What should the nurse identify as the area in which nursing diagnoses differ from medical diagnoses and collaborative problems?

A)Mental status of the client
B)Chronic nature of the illness
C)Nursing care focus
D)Prognosis

Question 14

The nurse is preparing to write nursing diagnoses for a client.What should the nurse recall about the NANDA label?

A)Must contain three components
B)Describes the health problem for which nursing therapy is given
C)Helps define medical diagnoses for nursing
D)Promotes a taxonomy of nursing

Question 15

After an assessment,the nurse reviews the list of client problems.For which problems should the nurse create nursing diagnoses?

A)The ones that the nurse is licensed to treat
B)The ones that address other health professionals' interventions
C)The ones that focus on the client's primary illness
D)The ones that have standardized care available

Question 16

A client who has been in a wheelchair for several years is currently experiencing problems with skin breakdown and urinary retention in addition to depression.Which diagnosis should the nurse select for this client?

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

Question 17

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.What is the etiology of this diagnosis?

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

Question 18

The nurse selects the nursing diagnosis of Enhanced readiness for spiritual well-being for a family.Which data cluster did the nurse use to support this diagnosis?

A)The family visits different congregations,the parents have been reflecting on their own spiritual upbringings,and the children are questioning rituals of their friends and friends' families.
B)The children attend Sunday school classes,one parent always attends services with the children,and the parents attempt interaction with congregational activities.
C)The grandparents go to weekly services and have formal interaction with clergy.
D)The children have attended private,religious schools,and the parents are involved in the school's activities.

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)Weakness and debilitation
C)Reports of fatigue
D)Physical activity

Question 20

A client comes to the clinic seeking information and education regarding healthy lifestyles and eating habits.Which type of diagnosis should the nurse select for this client?

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

Question 21

The nurse is providing care to a client.Which nursing diagnoses can the nurse apply when providing client care?
Standard Text: Select all that apply.

A)Ineffective Breathing Pattern
B)Risk of Infection
C)Readiness for Enhanced Nutrition
D)Readiness for Enhanced Family Coping
E)Anxiety

Question 22

The nurse is preparing to formulate nursing diagnoses for a client desiring information to help with chronic low back pain.Which human response patterns should the nurse keep in mind when formulating the diagnoses for this client?
Standard Text: Select all that apply.

A)Moving
B)Choosing
C)Perceiving
D)Anticipating
E)Communicating

Question 23

The nurse is using the PES model to write a nursing diagnosis.Which nursing diagnoses demonstrate that the nurse used this model appropriately?
Standard Text: Select all that apply.

A)Ineffective coping related to depression as evidenced by suicide attempt
B)Noncompliance (DASH diet)related to denial of having disease
C)Risk for infection related to recent surgery
D)Nutrition less than adequate related to anxiety as evidenced by weight loss of ten pounds
E)Ineffective Breathing Pattern as evidenced by cyanotic lips