A registered nurse is writing a diagnosis for a 28-year old male patient who is in traction due to multiple fractures from a motor vehicle accident. Which nursing actions are related to this step in the nursing process?
The nurse uses the nursing interview to collect patient data
The nurse analyzes data collected in the nursing assessment
The nurse develops a care plan for the patient
Then nurse points out the patient's strengths
The nurse assesses the patient's mental status
The nurse identifies community resources to help his family cope
A nurse is caring for an older adult patient who presents with labored respirations, productive cough and fever. What would be appropriate nursing diagnoses for this patient?
Bronchial pnemonia
Impaired gas exchange
Ineffective airway clearance
Potential complication: sepsis
Infection related to pneumonia
Risk for septic shock
After assessing a patient who is recovering from a stroke in a rehabilitation facility, a nurse interprets and analyzes the patient data. Which of the four basic conclusions has the nurse reached when identifying the need to collect more data to confirm a diagnosis of situational low self-esteem?
no problem
possible problem
actual nursing diagnosis
clinical problem other than nursing diagnosis
A nurse assesses a patient and formulates the following nursing diagnosis: Risk for Impaired Skin Integrity related to prescribed bedrest as evidenced by reddened areas of skin on the heels and back. Which phase represents the etiology of this diagnostic statemetn?
Risk for Impaired Skin Integrity
Related to prescribed bedrest
As evidenced by
As evidenced by reddened areas of skin on the heels and back
A nurse is counseling a 60 year old female patient who refuses to look at or care for a new colostomy. She tells the nurse "I don't care what I look like anymore. I don't even feel like washing my hair, let alone changing this bag." The nurse diagnoses Altered Health Maintenance. This is an example of what type of problem?
Collaborative problem
Interdisciplinary problem
Medical problem
Nursing problem
To determine the significance of a blood pressure reading of 148/100, it is first necessary for the nurse to
Compare this reading to standards
Check the taxonomy of nursing diagnoses for a pertinent label
Check a medical text for the signs and symptoms of high blood pressure
Consult with colleagues
When the initial nursing assessment revealed that a patient had not had a bowel movement for 2 days, the student nurse wrote the diagnostic label "constipation". Which of the following comments is the nurse most likely to hear from the instructor?
Hold on a minute, Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue
Job well done...you've identified this problem early and we can manage it before it becomes more acute
Is this an actual or a possible diagnosis
This is a medical, not a nursing problem
A nurse makes a clinical judgement that an African American male patient in a stressful job is more vulnerable to developing hypertension than White male patients in the same or similar situation. The nurse has formulated what type of nursing diagnoses?
Actual
Risk
Possible
Wellness
A nurse is writing nursing diagnosis for patients in a psychiatrist's office. Which nursing diagnosis are correctly written as two-part nursing diagnoses?
Ineffective Coping related to inability to maintain marriage
Defensive coping related to loss of job and economic security
Altered Thought Processes related to panic state
Decisional Conflict related to placement of parent in a long-term care facility
A nurse writes nursing diagnoses for patients and their families visiting a community health clinic. Which nursing diagnoses are correctly written as 3 part nursing diagnoses?
1) Disabled Family Coping related to lack of knowledge about home care of child on ventilator
2) Imbalanced Nutrition: Less Than Body Requirements related to inadequate caloric intake while striving to excel in gymnastics as evidenced by 20lb weight loss since beginning the gymnastics program, and greatly less than ideal body weight when compared to standard height and weight charts
3) Need to learn how to care for child on ventilator at home related to unexpected discharge of daughter after 3 month hospital stay as evidenced by repeated comments "I cannot do this", "I know I'll harm her because I'm not a nurse" and "I can't do medical things"
4) Spiritual Stress related to inability to accept diagnosis of terminal illness as evidenced by multiple comments such as "How could God do this to me", "I don't deserve this", "I don't understand, I tried to live my life well." and "How could God make me suffer this way?"
5) Caregiver Role Strain related to failure of home health aides to appropriately diagnose needs of family caregivers and initiate a plan to facilitate coping as evidenced by caregiver's loss of weight and clinical depression
Nursing provide the basis for selecting nursing that will achieve valued patient outcomes.
The purpose of diagnosis is to clarify the exact nature of the problems and risks that must be addressed to achieve the overall expected outcomes of care.
Nursing diagnoses are written to describe patient problems or issues that nurses can treat copendently.
() should raise a red flag for the nurse, who then looks for or of data that signal an actual or possible nursing diagnosis.
Nursing diagnosis should always be derived from ❌ rather than from ❌.
❌: Imbalanced Nutrition: More Than Body Requirements
❌: Intake of nutrients that exceeds metabolic needs
❌: Concentrating food intake at the end of day Sedentary activity level
❌: Excessive intake in relation to metabolic need Excessive intake in relation to physical activity
Most nursing diagnoses are written either as a 2-part statement listing the patient's problem and it cause or 3-part statement that also includes the problem's defining characteristics.
Problem: ❌ linked by: ❌ Etiology: ❌ linked by: ❌ Defining: ❌: ❌
After a tentative nursing diagnosis is formulated, it should not be validated, as it was validated during the assessment.
Patients who are able to participate in decision making should be encouraged to validate the diagnosis.
The nursing diagnosis taxonomy provides nursing with...
Common language
Legal information
Evaluative care
Discharge planning
A client is brought to the emergency in an unconscious condition, accompanied by his son. The client is having respiratory arrest and is put on a ventilator. What is the most appropriate nursing diagnosis for this client?
Ineffective breathing pattern
Impaired spontaneous ventilation
Which of the following is classified as a nursing diagnosis?
Grieving
Esophageal Cancer
Cholecystitis
Pneumonia
Which of the following nursing diagnoses has the highest priority when caring for an older client with Alzheimer's disease?
Impaired physical mobility
Impaired memory
Risk for injury
Self-care deficit
What information provides the nurse with accuracy when developing a nurse diagnosis?
A set of lab values
A set of clinical cues
Specific nursing interventions
Abnormal diagnostic tests
The act of analyzing and synthesizing cues requires what?
advanced practice
critical thinking
certification
attendance at NANDA
After educating a group of students on the different types of nursing diagnosis, the instructor determines that the education was successful when the students identify wellness diagnoses statements as consisting of how many parts?
2
1
4
3
What activity does the nurse perform during the diagnosing stage?
Establishes plan priorities with the client and family
Validates the identified health problems with the client
Prioritizes the client's health problems with input from the client
Identifies factors contributing to the client's health problems
Collects data to monitor quality and effectiveness of nursing practice
The nurse is examining the assessment data of a client and diagnoses a problem of impaired tissue perfusion based on the following assessment data cues: left foot cool/pale w/capillary refill > 3 seconds, diminished dorsalis pedis posterior tibial pulses, client complaint of cramping pain in left foot. The nurse is doing what?
formulating a nursing diagnoses
clustering significant data cues
validating the nursing diagnosis
identifying contributing factors
After assessing a client, a nurse identifies the nursing diagnosis: Ineffective Airway Clearance related to thick tracheobronchial secretions. The nurse would classify this nursing diagnosis as which type?
Which of the following best defines nursing diagnoses?
Identification of client problems that require collaboration with other health care professionals
Identification of client problems that nurses can treat independently
Identification of actual client problems, not including potential problems
Identification of signs and symptoms that identify diseases
Nursing diagnosis that require physician-prescribed and nurse-prescribed actions would be what type of problems?
Interdisciplinary health problems
Collaborative health problems
Independent health problems
Physician-developed problems
In the development of a nursing diagnosis for a client who has cachexia and decreased weight, what would be an appropriate nursing diagnosis?
Imbalanced Nutrition: Less than body requirements
Lack of adequate nutrition related to decreased calories
Anorexia nervosa and bulimia
Weight loss related to abdominal discomfort
The process of nursing diagnoses carries legal implications for nurses. Which of the following legal responsibilities exists for a nurse who has documented a nursing diagnosis related to a client's kidney failure?
Independently managing the client's kidney failure
Choosing interventions to resolve the client's kidney failure
Coordinating the treatment for the client's kidney failure
Reporting signs/symptoms related to the client's kidney failue
Which of the following statements appropriately identifies an at-risk nursing diagnosis for a woman 78 years of age who is confined to bed?
Ineffective airway clearance related to bed rest
Risk for impaired skin integrity related to bed rest
Potential for pneumonia related to inactivity
Immobility related to confinement to bed
A client with HIV has been admitted to a health care facility. Which of the following nursing diagnosis should be of the highest priority, keeping in mind the client's condition?
Risk for activity intolerance
Risk for ineffective coping
Risk for infection
Risk for imbalanced nutrition
What is the purpose of establishing a nursing diagnosis?
To meet accreditation criteria
To identify medical problems
To describe a functional health problem
To collaborate with the physician
The nurse formulates the following nursing diagnosis: Disturbed body image related to decreased ability to cope surgical removal of right breast. AEB client refuses to look at surgical site and client statement "I"m ugly. My husband will no longer find me desirable." Which of the following is the etiology?
"I"m ugly. My husband will no longer find me desirable."
refuses to look at surgical site
decreased ability to cope surgical removal of right breast
Disturbed body image
A male client age 67 years has right lower quadrant pain that has been diagnosed as appendicitis and subsequently treated by open appendectomy. How should the nurse document a potential complication related to this patient's diagnosis treatment?
Risk for respiratory complications due to anesthesia
PC: Atelectasis related to surgery
Potentially complicated respiration as a result of surgery
Client is at risk for impaired lung function due to anesthesia
A nurse who is caring for a client admitted to the nursing unit with acute abdominal pain formulates the care plan for the client. Which of the following nursing diagnosis is the highest priority for this client?
Disturbed sleep pattern
Activity intolerance
Impaired comfort
A nurse is caring for a client admitted with dehydration after completing a triathlon on a hot dry climate. The nurse identifies an appropriate nursing diagnosis for this client as: Deficient fluid volume related to insufficient fluid intake as evidenced by blood pressure 84/46, heart rate 145, concentrated urine, and client stating that he drank 200 mL of water during the 4 hour event. Identify the problem statement in the nursing diagnosis.
blood pressure 84/46, heart rate 145, concentrated urine
hot dry climate
insufficient fluid intake
Deficient fluid volume
A nurse is justified in independently identifying and documenting which of the following diagnoses related to impaired elimination?
Bowel incontinence
Irritable bowel syndrome
Small bowel obstruction
Ulcerative colitis
Which of the following errors has the nurse made in formulating the following nursing diagnosis: Prolonged immobility related to impaired skin integrity AEB one inch diameter open area on right buttocks surrounded by one inch margin of redness; wound surface clean and beefy red; no drainage or foul odor detected
Omitted the defining characteristics of the client health problem
Writing the diagnosis in terms of a need rather than a client response
Identified environmental factors rather than client factors as the problem
Reversed the health problem and etiology
A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain that is interfering w/her ability to ambulate. The nurse accurately documents which of the following as a nursing diagnosis in the client's records?
Ineffective physical mobility due to pain
Ineffective movement related to arthritis
Impaired movements due to pain
Impaired physical mobility related to pain
