1. After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse’s actions?
a. To form a language that can be encoded only by nurses
b. To distinguish the nurse’s role from the physician’s role
c. To develop clinical judgment based on other’s intuition d. To help nurses focus on the scope of medical practice
ANS: B
The standard formal nursing diagnosis serves several purposes. Nursing diagnoses distinguish the nurse’s role from that of the physician/health care provider and help nurses focus on the scope of nursing practice (not medical) while fostering the development of nursing knowledge. A nursing diagnosis provides the precise definition that gives all members of the health care team a common language for understanding the patient’s needs. A diagnosis is a clinical judgment based on information.
2. Which diagnosis will the nurse document in a patient’s care plan that is NANDA-I approved?
a. Sore throat b. Acute pain
c. Sleep apnea d. Heart failure
ANS: B
Acute pain is the only NANDA-I approved diagnosis listed. Sleep apnea and heart failure are medical diagnoses, and sore throat is subjective data.
3. A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
a. Ineffective breathing pattern related to pneumonia b. Risk for infection related to chest x-ray procedure
c. Risk for deficient fluid volume related to dehydration
Impaired gas exchange related to alveolar-capillary membrane d. changes
ANS: D
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The related to factor of alveolar-capillary membrane changes is accurately written because it is a patient response to the disease process of pneumonia that the nurse can treat. The related to factor should be the cause of the problem (nursing diagnosis) that a nurse can address. The related to factors of dehydration and pneumonia are all medical diagnoses that the nurse cannot change. A diagnostic test or a chronic dysfunction is not an etiology or a condition that a nursing intervention is able to treat.
4. The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?
a. Etiology
b. Nursing diagnosis
c. Collaborative problem d. Defining characteristic
ANS: A 2
The etiology, or related to factor, of tibial fracture is a medical diagnosis and needs to be revised. The nursing diagnosis is appropriate because the patient is unable to ambulate. A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient’s health status; there is no collaborative problem listed. The defining characteristic (subjective and objective data that support the diagnosis) is appropriate for Impaired physical mobility.
5. A nurse is using assessment data gathered about a patient and combining critical thinking
to develop a nursing diagnosis. What is the nurse doing?
a. Assigning clinical cues b. Defining characteristics c. Diagnostic reasoning
d. Diagnostic labeling
ANS: C
Diagnostic reasoning is defined as a process of using the assessment data gathered about a patient to logically explain a clinical judgment, in this case a nursing diagnosis. Defining characteristics are assessment findings that support the nursing diagnosis. Defining characteristics are the subjective and objective clinical cues, which a nurse gathers intentionally and unintentionally. The nurse organizes all of the patient’s data into meaningful and usable data clusters, which lead to a diagnostic conclusion. Diagnostic labeling is simply the name of the diagnosis.
6. A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?
a. Posttrauma syndrome b. Constipation
c. Acute pain d. Anxiety
ANS: C
Based on the assessment data provided, the only supportive evidence for one of the diagnosis options is “Reports only moderate discomfort,” which would support Acute pain. No supportive evidence is provided for any of the other diagnoses. The patient may indeed develop signs or symptoms of the other problems, but supportive data are presently lacking in the provided information.
7. The nurse is reviewing a patient’s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient’s kidney function lab results are abnormal, and the patient’s oral intake has significantly decreased since previous shifts. Which step of the nursing
process should the nurse proceed to after this review?
a. Diagnosis b. Planning
c. Implementation
d. Evaluation
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ANS: A
After a thorough assessment, the nurse should proceed to analyzing the data and formulating a nursing diagnosis before proceeding with developing the plan of care and determining appropriate interventions; this is the diagnosis phase. The evaluation phase involves determining whether the goals were met and interventions were effective.
8. A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self- catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?
a. Risk
b. Problem focused c. Health promotion
d. Collaborative problem
ANS: C
A health promotion nursing diagnosis is a clinical judgment concerning motivation and desire to increase well- being and actualize human health potential. A problem-focused nursing diagnosis describes a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, or community. A risk nursing diagnosis is a clinical judgment concerning the vulnerability of an individual, family, group or community for developing an undesirable human response to health conditions/life processes. A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient’s health status.
9. A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient’s blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse firstmake an error?
a. Assessment b. Diagnosis
c. Implementation
d. Evaluation
ANS: A
The diagnostic process should flow from the assessment. In this case, the nurse should have assessed the patient’s blood pressure before giving the medication. The nurse could have prevented the patient’s untoward reaction if the low blood pressure was assessed first. Diagnosis follows assessment. Administering the medication occurs in implementation, but this is not the first error. There are no errors in evaluation.
10. A nurse adds the following diagnosis to a patient’s care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic?
a. Decreased gastrointestinal motility
b. Pain medication
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c. Abdominal distention
d. Constipation
ANS: C
Abdominal distention, no reported bowel movement, and abdominal pain are the defining characteristics. Decreased gastrointestinal motility secondary to pain medication is an etiology or related to factor.
Constipation (problem or NANDA-1 diagnosis) is the identified problem derived from the defining characteristics.
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