Nursing Diagnosis | Nursing Test Banks

Nursing Diagnosis | Nursing Test Banks. 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 deᴀ 밄 nition 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. DIF:Understand (comprehension)REF:225 | 227 OBJ: Discuss how a nursing diagnosis guides nursing practice. TOP: Diagnosis 10/15/2016 Chapter 17: Nursing Diagnosis | Nursing Test Banks MSC:Management of Care 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. DIF:Understand (comprehension)REF:227 | 233 OBJ: Discuss how a nursing diagnosis guides nursing practice. TOP: Diagnosis MSC:Management of Care 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 inᴀ 밄 ltrates. Which nursing diagnosis did the nurse write? a. Ineᴀ 洅 ective breathing pattern related to pneumonia b. Risk for infection related to chest x-ray procedure c. Risk for deᴀ 밄 cient ᴀ 밄 uid volume related to dehydration d. Impaired gas exchange related to alveolar-capillary membrane changes ANS: D 10/15/2016 Chapter 17: Nursing Diagnosis | Nursing Test Banks 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. DIF:Apply (application)REF:230 | 232 | 236 OBJ: Discuss the relationship of critical thinking to the nursing diagnostic process. TOP iagnosisMSC:Management of Care 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. Deᴀ 밄 ning characteristic ANS: A 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 deᴀ 밄 ning characteristic (subjective and objective data that support the diagnosis) is appropriate for Impaired physical mobility. DIF:Apply (application)REF:233 | 235 | 236 OBJ: Diᴀ 洅 erentiate among a nursing diagnosis, medical diagnosis, and collaborative problem. TOP iagnosisMSC:Management of Care 10/15/2016 Chapter 17: Nursing Diagnosis | Nursing Test Banks 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. Deᴀ 밄 ning characteristics c. Diagnostic reasoning d. Diagnostic labeling ANS: C Diagnostic reasoning is deᴀ 밄 ned as a process of using the assessment data gathered about a patient to logically explain a clinical judgment, in this case a nursing diagnosis. Deᴀ 밄 ning characteristics are assessment ᴀ 밄 ndings that support the nursing diagnosis. Deᴀ 밄 ning 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. DIF:Understand (comprehension)REF:230 OBJ: Discuss the relationship of critical thinking to the nursing diagnostic process. TOP iagnosisMSC:Management of Care 6. A patient presents to the emergency department following a motor vehicle crash and suᴀ 洅 ers 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 10/15/2016 Chapter 17: Nursing Diagnosis | Nursing Test Banks 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. DIF:Apply (application)REF:230 | 233 OBJ: Discuss the relationship of critical thinking to the nursing diagnostic process. TOP iagnosisMSC:Management of Care 7. The nurse is reviewing a patient’s database for signiᴀ 밄 cant 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 signiᴀ 밄 cantly 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 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 eᴀ 洅 ective. DIF:Apply (application)REF:226 | 230 OBJ: Describe the steps of the nursing diagnostic process. TOP: Diagnosis 10/15/2016 Chapter 17: Nursing Diagnosis | Nursing Test Banks MSC:Management of Care 8. A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning selfcatheterization 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 wellbeing 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. DIF:Apply (application)REF:227 | 230 OBJ escribe the diᴀ 洅 erences among health promotion, problem focused, and risk nursing diagnoses.TOP iagnosisMSC:Management of Care.