NURS-502 | CH. 11 DIAGNOSING EXAM QUESTIONS WITH VERIFIED SOLUTIONS LATEST UPDATE
2026
1) After an assessment, the nurse reviews the list of client problems. For which problems should the
nurse create nursing diagnoses?
1. The ones that the nurse is licensed to treat
2. The ones that address other health professionals' interventions
3. The ones that focus on the client's primary illness
4. The ones that have standardized care available - Answers Answer: 1
Explanation: The domain of nursing diagnoses includes only those health states that nurses are
educated on and licensed to treat. A nursing diagnosis is a judgment made only after data collection.
Nursing diagnoses describe a continuum of health states: deviations from health, presence of risk
factors, and areas of enhanced personal growth.
2) 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?
1. Syndrome diagnosis
2. Risk nursing diagnosis
3. Actual diagnosis
4. Health promotion diagnosis - Answers Answer: 1
Explanation: A syndrome diagnosis is a diagnosis that is associated with a cluster of other diagnoses
(in this situation, Urinary elimination alteration, Impaired skin integrity, and Powerlessness). Risk,
actual, or health promotion diagnoses would not be appropriate for this client.
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?
1. The client's eyes are closed.
2. The client's skin is pale and mottled.
3. The client's spouse is asleep in the chair next to the bed.
4. The television is on and the volume is turned up. - Answers Answer: 2
Explanation: Nurses draw on knowledge and experience to compare client data to standards and
norms and to identify significant and relevant observations. An observation is considered significant if
it points to changes in the client's health status or pattern, varies from norms of the client population,
or indicates a developmental delay. Pale, mottled skin could indicate coldness, a problem with
circulation, or even death. Closed eyes, visitors, and environmental noise are not used to identify a
nursing diagnosis.
4) The nurse selects the nursing diagnosis of Willingness to learn about spiritual well-being for a
family. Which data cluster did the nurse use to support this diagnosis?
1. 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.
2. The children attend Sunday school classes, one parent always attends services with the children,
and the parents attempt interaction with congregational activities.
3. The grandparents go to weekly services and have formal interaction with clergy.
4. The children have attended private, religious schools, and the parents are involved in the school's
activities. - Answers Answer: 1
Explanation: A health promotion diagnosis relates to clients' preparedness to implement behaviors to
improve their health condition. These diagnosis labels begin with the phrase Willingness to learn
about the health maintenance or Willingness to change health practices. The data cluster that
describes the questioning, searching, and reflecting would support an attitude of readiness.
5) The graduate nurse is struggling with identifying cues from clustered data. What should the nurse
use to recognize data patterns and cues?
1. Depend on knowledge gained from peers' experiences.
2. Work with seasoned and experienced nurses and learn from them.
3. Take assessment notes and utilize information from textbooks for comparison.
4. Know that this will take time, and experience is the best teacher. - Answers Answer: 3
Explanation: The novice nurse must take careful assessment notes, search data for abnormal cues,
and use textbook resources for comparing the client's cues with the defining characteristics and
etiologic factors of the accepted nursing diagnoses.
, 6) 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?
1. Strengths can be an aid to mobilizing health and the healing process.
2. The client will be more active in the plan.
3. It will be easier for the nurse to educate the client about other interventions.
4. The nurse won't have to spend time going over the pathology of the client's disease. - Answers
Answer: 1
Explanation: Establishing strengths, resources, and ability to cope will help the client develop a more
well-rounded self-concept and self-image. Strengths can be an aid to mobilizing health and
regenerative processes.
7) 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?
1. Pain due to unknown factors
2. Pain related to unknown etiology
3. Pain caused by psychosomatic condition
4. Pain manifested by client's report - Answers Answer: 2
Explanation: The second part of the nursing diagnosis statement is the etiology (E)-the factors
contributing to or probable causes-and should be joined to the first part, the problem (P), by the
words "related to" rather than "due to." The phrase "related to" implies a relationship between the
problem and the cause. In this situation, the cause is unknown, but the problem is evident.
8) 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?
1. Constipation, due to tissue trauma, manifested by no bowel movement for 2 days
2. Risk for infection, because of new incision, related to episiotomy
3. Ineffective breastfeeding, related to lack of motivation, secondary to exhaustion
4. Altered urinary elimination, secondary to childbirth - Answers Answer: 3
Explanation: The problem statement is listed first followed by the etiology-factors that contribute to
or are the cause of the client's response. The two parts are joined by the words "related to," implying
a relationship between the two. Adding a second part to the etiology statement makes it more
descriptive and useful.
9) 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?
1. Chronic low self-esteem, related to factors too numerous to mention
2. Risk for self-harm, related to many psychiatric problems
3. Impaired social interaction, due to long history of institutionalization
4. Alteration in thought processes, related to complex factors - Answers Answer: 4
Explanation: The phrase "complex factors" may be used when there are too many etiologic factors or
when they are too complex to state in a brief phrase. The actual cause of this client's altered thought
process may be due to psychiatric diagnoses, medication tolerances and noncompliance, history of
institutionalization, and life history of mental disease. This is a variation of the basic two-part
statement but is acceptable to use.
10) 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?
1. Understanding what is normal versus what is not normal
2. Verifying
3. Consulting resources
4. Basing diagnoses on patterns - Answers Answer: 2
Explanation: The nurse, while taking the information and collecting data, begins to hypothesize
possible explanations of the data and then realizes all diagnoses are only tentative until they are
verified. The client and family should be included in the beginning and also at the end of the
diagnostic process to verify the nurse's diagnoses.
11) After formulating several diagnoses, the nurse does not understand the reason for some of the
discrepancies in the client's laboratory values and diagnostic tests, when comparing to norms and
standards. Which action should the nurse take?
2026
1) After an assessment, the nurse reviews the list of client problems. For which problems should the
nurse create nursing diagnoses?
1. The ones that the nurse is licensed to treat
2. The ones that address other health professionals' interventions
3. The ones that focus on the client's primary illness
4. The ones that have standardized care available - Answers Answer: 1
Explanation: The domain of nursing diagnoses includes only those health states that nurses are
educated on and licensed to treat. A nursing diagnosis is a judgment made only after data collection.
Nursing diagnoses describe a continuum of health states: deviations from health, presence of risk
factors, and areas of enhanced personal growth.
2) 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?
1. Syndrome diagnosis
2. Risk nursing diagnosis
3. Actual diagnosis
4. Health promotion diagnosis - Answers Answer: 1
Explanation: A syndrome diagnosis is a diagnosis that is associated with a cluster of other diagnoses
(in this situation, Urinary elimination alteration, Impaired skin integrity, and Powerlessness). Risk,
actual, or health promotion diagnoses would not be appropriate for this client.
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?
1. The client's eyes are closed.
2. The client's skin is pale and mottled.
3. The client's spouse is asleep in the chair next to the bed.
4. The television is on and the volume is turned up. - Answers Answer: 2
Explanation: Nurses draw on knowledge and experience to compare client data to standards and
norms and to identify significant and relevant observations. An observation is considered significant if
it points to changes in the client's health status or pattern, varies from norms of the client population,
or indicates a developmental delay. Pale, mottled skin could indicate coldness, a problem with
circulation, or even death. Closed eyes, visitors, and environmental noise are not used to identify a
nursing diagnosis.
4) The nurse selects the nursing diagnosis of Willingness to learn about spiritual well-being for a
family. Which data cluster did the nurse use to support this diagnosis?
1. 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.
2. The children attend Sunday school classes, one parent always attends services with the children,
and the parents attempt interaction with congregational activities.
3. The grandparents go to weekly services and have formal interaction with clergy.
4. The children have attended private, religious schools, and the parents are involved in the school's
activities. - Answers Answer: 1
Explanation: A health promotion diagnosis relates to clients' preparedness to implement behaviors to
improve their health condition. These diagnosis labels begin with the phrase Willingness to learn
about the health maintenance or Willingness to change health practices. The data cluster that
describes the questioning, searching, and reflecting would support an attitude of readiness.
5) The graduate nurse is struggling with identifying cues from clustered data. What should the nurse
use to recognize data patterns and cues?
1. Depend on knowledge gained from peers' experiences.
2. Work with seasoned and experienced nurses and learn from them.
3. Take assessment notes and utilize information from textbooks for comparison.
4. Know that this will take time, and experience is the best teacher. - Answers Answer: 3
Explanation: The novice nurse must take careful assessment notes, search data for abnormal cues,
and use textbook resources for comparing the client's cues with the defining characteristics and
etiologic factors of the accepted nursing diagnoses.
, 6) 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?
1. Strengths can be an aid to mobilizing health and the healing process.
2. The client will be more active in the plan.
3. It will be easier for the nurse to educate the client about other interventions.
4. The nurse won't have to spend time going over the pathology of the client's disease. - Answers
Answer: 1
Explanation: Establishing strengths, resources, and ability to cope will help the client develop a more
well-rounded self-concept and self-image. Strengths can be an aid to mobilizing health and
regenerative processes.
7) 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?
1. Pain due to unknown factors
2. Pain related to unknown etiology
3. Pain caused by psychosomatic condition
4. Pain manifested by client's report - Answers Answer: 2
Explanation: The second part of the nursing diagnosis statement is the etiology (E)-the factors
contributing to or probable causes-and should be joined to the first part, the problem (P), by the
words "related to" rather than "due to." The phrase "related to" implies a relationship between the
problem and the cause. In this situation, the cause is unknown, but the problem is evident.
8) 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?
1. Constipation, due to tissue trauma, manifested by no bowel movement for 2 days
2. Risk for infection, because of new incision, related to episiotomy
3. Ineffective breastfeeding, related to lack of motivation, secondary to exhaustion
4. Altered urinary elimination, secondary to childbirth - Answers Answer: 3
Explanation: The problem statement is listed first followed by the etiology-factors that contribute to
or are the cause of the client's response. The two parts are joined by the words "related to," implying
a relationship between the two. Adding a second part to the etiology statement makes it more
descriptive and useful.
9) 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?
1. Chronic low self-esteem, related to factors too numerous to mention
2. Risk for self-harm, related to many psychiatric problems
3. Impaired social interaction, due to long history of institutionalization
4. Alteration in thought processes, related to complex factors - Answers Answer: 4
Explanation: The phrase "complex factors" may be used when there are too many etiologic factors or
when they are too complex to state in a brief phrase. The actual cause of this client's altered thought
process may be due to psychiatric diagnoses, medication tolerances and noncompliance, history of
institutionalization, and life history of mental disease. This is a variation of the basic two-part
statement but is acceptable to use.
10) 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?
1. Understanding what is normal versus what is not normal
2. Verifying
3. Consulting resources
4. Basing diagnoses on patterns - Answers Answer: 2
Explanation: The nurse, while taking the information and collecting data, begins to hypothesize
possible explanations of the data and then realizes all diagnoses are only tentative until they are
verified. The client and family should be included in the beginning and also at the end of the
diagnostic process to verify the nurse's diagnoses.
11) After formulating several diagnoses, the nurse does not understand the reason for some of the
discrepancies in the client's laboratory values and diagnostic tests, when comparing to norms and
standards. Which action should the nurse take?
