Deck 12: Diagnosing

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?

A) disturbed thought processes
B) related to
C) Alzheimer's disease
D) incoherent language

Answer 1

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?

A) Validate the nursing diagnosis
B) Identify potential complications
C) Cross-reference the nursing diagnosis with medical diagnoses
D) Modify interventions based on the diagnosis

Answer 2

Validate the nursing diagnosis

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?

A) Presuming to know the factors contributing to the problem
B) Identifying a problem that cannot be changed
C) Identifying a problem without corroborating evidence in the statement
D) Neglecting to identify potential complications related to the problem

Answer 3

Presuming to know the factors contributing to the problem

Question 4

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

A) The client problem
B) The potential complication
C) The nursing diagnosis
D) The medical diagnosis

Question 5

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

A) The nurse may make a diagnosis, but the physician is responsible for making sure it is appropriate for the client.
B) The nurse practitioner is responsible for making all nursing diagnoses and determining if they are appropriate for the client.
C) The nurse must decide if he or she is qualified to make a nursing diagnosis and will accept responsibility for treating it.
D) The health care facility directs the nursing diagnosis in order to receive payment for services performed.

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?

A) Neither appendicitis nor acute pain
B) Both appendicitis and acute pain
C) Appendicitis
D) Acute pain

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?

A) Ineffective airway clearance as evidenced by inability to clear secretions
B) Ineffective health maintenance as evidenced by unhealthy habits
C) Ineffective breathing pattern related to pneumonia
D) Ineffective therapeutic regimen management due to smoking

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?

A) "I often have diarrhea after I eat spicy foods."
B) "My skin is so dry I just can't keep from scratching."
C) "I get out of breath when I walk a few steps."
D) "I just feel so bad about myself these days."

Question 9

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

A) Prescribing medications
B) Monitoring health status changes
C) Ordering diagnostic examinations
D) Performing surgical procedures

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?

A) No problem
B) Possible problem
C) Actual problem
D) Clinical problem

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?

A) Trust clinical judgment and experience over asking for help.
B) Respect clinical intuition, but never allow it to determine a diagnosis.
C) Recognize personal biases as a strength in formulating diagnoses.
D) Keep an open mind and trust your intuition when formulating 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?

A) Selecting nursing interventions to meet expected outcomes
B) Establishing a database of information for future comparison
C) Mutually establishing desired outcomes of the plan of care
D) Evaluating the effectiveness of the established plan of care

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?

A) No problem
B) Possible problem
C) Actual problem
D) Clinical problem

Question 14

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

A) Place defining characteristics after the etiology and link them by the phrase "as evidenced by."
B) Phrase the nursing diagnosis as a client need.
C) Place the etiology prior to the client problem and linked by the phrase "related to."
D) Incorporate subjective and judgmental terminology.

Question 15

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

A) "needs nasal oxygen to improve breathing"
B) "cough related to ineffective airway clearance"
C) "ineffective airway clearance related to thick mucus"
D) "refuses to cough and expectorate thick mucus"

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:

A) medical diagnosis.
B) nursing diagnosis.
C) collaborative problem.
D) goal for care.

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?

A) The client is more vulnerable to certain problems than other individuals would be.
B) The diagnoses present significant risks for the development of medical diagnoses.
C) The data necessary to make a definitive nursing diagnosis is absent.
D) The diagnosis has yet to be confirmed by another practitioner.

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?

A) Nothing; this observation is not important.
B) The mother is just behaving as all mothers do.
C) A baby is not capable of having strengths.
D) Nurturing is a strength for developing infants.

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?

A) To collect information about subjective and objective data
B) To correlate nursing and medical diagnostic criteria
C) To identify etiologies of health problems
D) To evaluate mutually developed expected outcomes

Question 20

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

A) A cluster of several significant cues of data that suggest a particular health problem
B) A single, definitive cue that is closely associated with a common diagnosis
C) A cue that can be verified by objective, medical data
D) A group of related nursing diagnoses that exist within the same NANDA-approved domain

Question 21

A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues provide organization or ...

A) Categorizing
B) Diagnosing
C) Grouping
D) Clustering

Question 22

Which of the following reflects the diagnosis phase?

A) The nurse identifies that the client does not tolerate activity.
B) The nurse performs wound care using sterile technique.
C) The nurse sets a tolerable pain rating with the client.
D) The nurse documents the client's response to pain medication.

Question 23

The nurse is providing care for a client who experienced an ischemic stroke five days ago. Which of the following diagnoses would the nurse be justified in identifying and documenting in the care of this client? Select all that apply.

A) Dysphagia
B) Bowel Incontinence
C) Impaired Swallowing
D) Impaired Physical Mobility
E) Risk for Hemiparesis

Question 24

A nursing diagnosis is written as Disturbed Self-Esteem related to presence of large scar over left side of face. What does the phrase "Disturbed Self-Esteem" identify?

A) The expected outcome of the plan of care
B) A cue to determining a health problem
C) The major defining characteristic of a health problem
D) The health state or problem of the client

Question 25

A client who has to undergo a parathyroidectomy is worried that he may have to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan?

A) Risk for impaired physical mobility due to surgery
B) Ineffective denial related to poor coping mechanisms
C) Disturbed body image related to the incision scar
D) Risk of injury related to surgical outcomes

Question 26

Of all the benefits of using nursing diagnoses, which one is probably the most important to nurses?

A) Defining the domain of nursing practice
B) Informing patients of their care
C) Improving communication among nurses
D) Structuring curricular content

Question 27

A nurse who is caring for an unresponsive client formulates the nursing diagnosis, "Risk for Aspiration related to reduced level of consciousness." The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis?

A) Is written as a two-part statement
B) Describes human response to a health problem
C) Describes potential for enhancement to a higher state
D) Made when not enough evidence supports the problem

Question 28

A nurse is formulating a diagnosis for a client who is reliving a brutal mugging that took place several months ago. The client is crying uncontrollably and states that he "can't live with this fear." Which of the following diagnoses for this client is correctly written?

A) Post-trauma syndrome related to being attacked
B) Psychological overreaction related to being attacked
C) Needs assistance coping with attack
D) Mental distress related to being attacked

Question 29

In the nursing diagnosis Disturbed Self-Esteem related to presence of large scar over left side of face, what part of the nursing diagnosis is "presence of large scar over left side of face"?

A) Etiology
B) Problem
C) Defining characteristics
D) Client need

Question 30

A student identifies Fatigue as a health problem and nursing diagnosis for a client receiving home care for treatment of metastatic cancer. What statement or question would be best to validate this client problem?

A) "I have assessed you and find you are fatigued."
B) "I analyzed and interpreted your information as fatigue."
C) "Why are you so tired all the time?"
D) "I think fatigue is a problem for you. Do you agree?"

Question 31

What is the nurse accountable for, according to the state nurse practice act?

A) Continuing education
B) Nursing diagnoses
C) Prescribing medications
D) Mentoring other nurses

Question 32

After assessing a client, the nurse formulates several nursing diagnoses. Which of the following would the nurse identify as an actual nursing diagnosis?

A) Impaired urinary elimination
B) Readiness for enhanced sleep
C) Risk for infection
D) Possible impaired adjustment

Question 33

According to Maslow's hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure?

A) Ineffective airway clearance
B) Ineffective coping
C) Impaired urinary elimination
D) Risk for body image disturbance

Question 34

A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling makes his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client's concern?

A) Impaired physical mobility
B) Disturbed body image
C) Risk for infection
D) Risk for social isolation

Question 35

Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics?

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