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Chapter 12: Diagnosing

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UNIT III: Person-Centered Care and the Nursing Process Chapter 12: Diagnosing
Alexandra Bozan
Quiz by Alexandra Bozan, updated more than 1 year ago
Alexandra Bozan
Created by Alexandra Bozan about 7 years ago
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Question 1

Question
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?
Answer
  • 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

Question 2

Question
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?
Answer
  • Bronchial pnemonia
  • Impaired gas exchange
  • Ineffective airway clearance
  • Potential complication: sepsis
  • Infection related to pneumonia
  • Risk for septic shock

Question 3

Question
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?
Answer
  • no problem
  • possible problem
  • actual nursing diagnosis
  • clinical problem other than nursing diagnosis

Question 4

Question
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?
Answer
  • Risk for Impaired Skin Integrity
  • Related to prescribed bedrest
  • As evidenced by
  • As evidenced by reddened areas of skin on the heels and back

Question 5

Question
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?
Answer
  • Collaborative problem
  • Interdisciplinary problem
  • Medical problem
  • Nursing problem

Question 6

Question
To determine the significance of a blood pressure reading of 148/100, it is first necessary for the nurse to
Answer
  • 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

Question 7

Question
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?
Answer
  • 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

Question 8

Question
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?
Answer
  • Actual
  • Risk
  • Possible
  • Wellness

Question 9

Question
A nurse is writing nursing diagnosis for patients in a psychiatrist's office. Which nursing diagnosis are correctly written as two-part nursing diagnoses?
Answer
  • 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

Question 10

Question
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?
Answer
  • 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

Question 11

Question
Nursing [blank_start]diagnosis[blank_end] provide the basis for selecting nursing [blank_start]interventions[blank_end] that will achieve valued patient outcomes.
Answer
  • diagnosis
  • interventions

Question 12

Question
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.
Answer
  • True
  • False

Question 13

Question
Nursing diagnoses are written to describe patient problems or issues that nurses can treat copendently.
Answer
  • True
  • False

Question 14

Question
[blank_start]Significant[blank_end] [blank_start]data[blank_end] ([blank_start]cue[blank_end]) should raise a red flag for the nurse, who then looks for [blank_start]patterns[blank_end] or [blank_start]clusters[blank_end] of data that signal an actual or possible nursing diagnosis.
Answer
  • Significant
  • data
  • cue
  • patterns
  • clusters

Question 15

Question
Nursing diagnosis should always be derived from [blank_start]clusters of significant data[blank_end] rather than from [blank_start]one single cue[blank_end].
Answer
  • clusters of significant data
  • one single cue

Question 16

Question
[blank_start]Label[blank_end]: Imbalanced Nutrition: More Than Body Requirements [blank_start]Definition[blank_end]: Intake of nutrients that exceeds metabolic needs [blank_start]Defining Characteristics[blank_end]: Concentrating food intake at the end of day Sedentary activity level [blank_start]Related Factors[blank_end]: Excessive intake in relation to metabolic need Excessive intake in relation to physical activity
Answer
  • Label
  • Definition
  • Defining Characteristics
  • Related Factors

Question 17

Question
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.
Answer
  • True
  • False

Question 18

Question
Problem: [blank_start]Bathing/Hygiene Self-Care Deficit[blank_end] linked by: [blank_start]related to[blank_end] Etiology: [blank_start]Fear of falling in the tub and obesity[blank_end] linked by: [blank_start]as evidenced by[blank_end] Defining: [blank_start]Strong body and urine odor, unclean hair[blank_end]: [blank_start]"I'm afraid I'll fall in the tub"[blank_end]
Answer
  • Bathing/Hygiene Self-Care Deficit
  • related to
  • Fear of falling in the tub and obesity
  • as evidenced by
  • Strong body and urine odor, unclean hair
  • "I'm afraid I'll fall in the tub"

Question 19

Question
After a tentative nursing diagnosis is formulated, it should not be validated, as it was validated during the assessment.
Answer
  • True
  • False

Question 20

Question
Patients who are able to participate in decision making should be encouraged to validate the diagnosis.
Answer
  • True
  • False

Question 21

Question
The nursing diagnosis taxonomy provides nursing with...
Answer
  • Common language
  • Legal information
  • Evaluative care
  • Discharge planning

Question 22

Question
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?
Answer
  • Ineffective airway clearance
  • Ineffective breathing pattern
  • Impaired spontaneous ventilation
  • Impaired gas exchange

Question 23

Question
Which of the following is classified as a nursing diagnosis?
Answer
  • Grieving
  • Esophageal Cancer
  • Cholecystitis
  • Pneumonia

Question 24

Question
Which of the following nursing diagnoses has the highest priority when caring for an older client with Alzheimer's disease?
Answer
  • Impaired physical mobility
  • Impaired memory
  • Risk for injury
  • Self-care deficit

Question 25

Question
What information provides the nurse with accuracy when developing a nurse diagnosis?
Answer
  • A set of lab values
  • A set of clinical cues
  • Specific nursing interventions
  • Abnormal diagnostic tests

Question 26

Question
The act of analyzing and synthesizing cues requires what?
Answer
  • advanced practice
  • critical thinking
  • certification
  • attendance at NANDA

Question 27

Question
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?
Answer
  • 2
  • 1
  • 4
  • 3

Question 28

Question
What activity does the nurse perform during the diagnosing stage?
Answer
  • 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

Question 29

Question
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?
Answer
  • formulating a nursing diagnoses
  • clustering significant data cues
  • validating the nursing diagnosis
  • identifying contributing factors

Question 30

Question
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?
Answer
  • Actual
  • Wellness
  • Possible
  • Risk

Question 31

Question
Which of the following best defines nursing diagnoses?
Answer
  • 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

Question 32

Question
Nursing diagnosis that require physician-prescribed and nurse-prescribed actions would be what type of problems?
Answer
  • Interdisciplinary health problems
  • Collaborative health problems
  • Independent health problems
  • Physician-developed problems

Question 33

Question
In the development of a nursing diagnosis for a client who has cachexia and decreased weight, what would be an appropriate nursing diagnosis?
Answer
  • Imbalanced Nutrition: Less than body requirements
  • Lack of adequate nutrition related to decreased calories
  • Anorexia nervosa and bulimia
  • Weight loss related to abdominal discomfort

Question 34

Question
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?
Answer
  • 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

Question 35

Question
Which of the following statements appropriately identifies an at-risk nursing diagnosis for a woman 78 years of age who is confined to bed?
Answer
  • 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

Question 36

Question
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?
Answer
  • Risk for activity intolerance
  • Risk for ineffective coping
  • Risk for infection
  • Risk for imbalanced nutrition

Question 37

Question
What is the purpose of establishing a nursing diagnosis?
Answer
  • To meet accreditation criteria
  • To identify medical problems
  • To describe a functional health problem
  • To collaborate with the physician

Question 38

Question
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?
Answer
  • "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

Question 39

Question
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?
Answer
  • 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

Question 40

Question
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?
Answer
  • Disturbed sleep pattern
  • Activity intolerance
  • Disturbed body image
  • Impaired comfort

Question 41

Question
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.
Answer
  • blood pressure 84/46, heart rate 145, concentrated urine
  • hot dry climate
  • insufficient fluid intake
  • Deficient fluid volume

Question 42

Question
A nurse is justified in independently identifying and documenting which of the following diagnoses related to impaired elimination?
Answer
  • Bowel incontinence
  • Irritable bowel syndrome
  • Small bowel obstruction
  • Ulcerative colitis

Question 43

Question
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
Answer
  • 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

Question 44

Question
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?
Answer
  • Ineffective physical mobility due to pain
  • Ineffective movement related to arthritis
  • Impaired movements due to pain
  • Impaired physical mobility related to pain
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