NSG 117 Exam 3 Practice (Evidence based, Clinical decision making, Nursing process),
Managing Patient
The nursing diagnosis Impaired Parenting related to mother's developmental delay is an example of a(n):
A. Risk nursing diagnosis.
B. Problem-focused nursing diagnosis.
C. Health promotion nursing diagnosis.
D. Wellness nursing diagnosis.
B
This is an example of a problem-focused nursing diagnosis with a related factor, based on NANDA-I diagnostic
terminology. Most health promotion diagnoses do not have established related factors based on NANDA-I; their
use is optional. Wellness diagnoses are not one of the types of NANDA-I diagnoses.
A nurse interviewed and conducted a physical examination of a patient. Among the assessment data the
nurse gathered were an increased respiratory rate, the patient reporting difficulty breathing while lying flat,
and pursed-lip breathing. This data set is an example of:
A. Collaborative data set.
B. Diagnostic label.
C. Related factors.
D. Data cluster.
D
A data cluster is a set of cues (i.e., the signs or symptoms gathered during assessment).
A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing
diagnosis is Diarrhea related to intestinal colitis. For which of the following reasons is this an incorrectly
stated diagnostic statement?
A. Identifying the clinical sign instead of an etiology
B. Identifying a diagnosis on the basis of prejudicial judgment
C. Identifying the diagnostic study rather than a problem caused by the diagnostic study
D. Identifying the medical diagnosis instead of the patient's response to the diagnosis.
D
Intestinal colitis is a medical diagnosis. The related factor in a nursing diagnostic statement is always within the
,domain of nursing practice and a condition that responds to nursing interventions. Nursing interventions do not
change a medical diagnosis.
A nurse is assigned to a new patient admitted to the nursing unit following admission through the
emergency department. The nurse collects a nursing history and interviews the patient. What are the steps
for making a nursing diagnosis in the correct order, beginning with the first step?
1. Considers context of patient's health problem and selects a related factor
2. Reviews assessment data, noting objective and subjective clinical information
3. Clusters clinical cues that form a pattern
4. Chooses diagnostic label
A. 2, 3, 4, 1
B. 3, 2, 4, 1
C. 2, 3, 1, 4
D. 1, 4, 3, 2
A
This is the correct steps for making a nursing diagnosis.
A nursing student reports to a lead charge nurse that his assigned patient seems to be less alert and his
blood pressure is lower, dropping from 140/80 to 110/60. The nursing student states, "I believe this is a
nursing diagnosis of Deficient Fluid Volume." The lead charge nurse immediately goes to the patient's
room with the student to assess the patient's orientation, heart rate, skin turgor, and urine output for last 8
hours. The lead charge nurse suspects that the student has made which type of diagnostic error?
A. Insufficient cluster of cues
B. Disorganization
C. Insufficient number of cues
D. Evidence that another diagnosis is more likely
C
It is likely the charge nurse suspects that the student has not collected enough cues to support the diagnosis. A
change in blood pressure and mental status changes are significant findings that can be attributed to fluid volume
excess and other diagnoses. The recommendation of the symptom cluster by the registered nurse would allow
the student to have sufficient data to confirm a deficient fluid volume.
,A nurse in a mother-baby clinic learns that a 16-year-old has given birth to her first child and has not been
to a well-baby class yet. The nurse's assessment reveals that the infant cries when breastfeeding and has
difficulty latching on to the nipple. The infant has not gained weight over the last 2 weeks. The nurse
identifies the patient's nursing diagnosis as Ineffective Breastfeeding. Which of the following is the best
"related to" factor?
A. Infant crying at breast
B. Infant unable to latch on to breast correctly
C. Mother's deficient knowledge
D. Lack of infant weight gain
C
In this scenario the related factor is the mother's deficient knowledge. A related factor is a condition, historical
factor, or etiology that gives a context for the defining characteristics, in this case the infant crying, inability to
latch on to breast, and absent weight gain.
A nurse assesses a young woman who works part time but also cares for her mother at home. The nurse
reviews clusters of data that include the patient's report of frequent awakenings at night, reduced ability to
think clearly at work, and a sense of not feeling well rested. Which of the following diagnoses is in the
correct PES format?
A. Disturbed Sleep Pattern evidenced by frequent awakening
B. Disturbed Sleep Pattern related to family caregiving responsibilities
C. Disturbed Sleep Pattern related to need to improve sleep habits
D. Disturbed Sleep Pattern related to caregiving responsibilities as evidenced by frequent awakening and
not feeling rested
D
A nursing diagnosis in a PES format includes the diagnostic label, related factor, and the defining characteristics
by which the diagnosis is evidenced. The second nursing diagnosis is the correct format in the two-part format for
writing a diagnosis. The first diagnosis has no related factor. The third diagnosis is an error, using a goal as a
related factor.
A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient.
The student has assessed that the patient is undergoing radiation treatment and has had liquid stool and
the skin is clean and intact; therefore she selects the nursing diagnosis Impaired Skin Integrity. The faculty
member explains that the student has made a diagnostic error for which of the following reasons?
, A. Incorrect clustering
B. Wrong diagnostic label
C. Condition is a collaborative problem.
D. Premature closure of clusters
B
The more appropriate nursing diagnosis for this patient would be Risk for Impaired Skin Integrity because the
patient's skin is clean and intact. A risk nursing diagnosis is appropriate because the patient has two risk factors,
radiation and secretions on the skin.
Review the following problem-focused nursing diagnoses and identify the diagnoses that are stated
correctly. (Select all that apply.)
A. Impaired Skin Integrity related to physical immobility
B. Fatigue related to heart disease
C. Nausea related to gastric distention
D. Need for improved Oral Mucosa Integrity related to inflamed mucosa
E. Risk for Infection related to surgery
A, C
The related factors in diagnoses "Fatigue related to heart disease" and "Need for improved oral mucosa integrity
related to inflamed mucosa" are incorrect. The related factor of a medical diagnosis (in Fatigue related to heart
disease) cannot be corrected through nursing intervention. In "Need for improved oral mucosa integrity related to
inflamed mucosa" there is no diagnosis, but instead a goal of care. "Risk for infection related to surgery" is
incorrect; risk nursing diagnoses do not have defining characteristics or related factors because they have not
occurred yet.
A nurse reviews data gathered regarding a patient's ability to cope with loss. The nurse compares the
defining characteristics for Ineffective Coping with those for Readiness for Enhanced Coping and selects
Ineffective Coping as the correct diagnosis. This is an example of the nurse avoiding an error in: (Select all
that apply.)
A. Data collection.
B. Data clustering.
C. Data interpretation.
D. Making a diagnostic statement.
E. Goal setting.
Managing Patient
The nursing diagnosis Impaired Parenting related to mother's developmental delay is an example of a(n):
A. Risk nursing diagnosis.
B. Problem-focused nursing diagnosis.
C. Health promotion nursing diagnosis.
D. Wellness nursing diagnosis.
B
This is an example of a problem-focused nursing diagnosis with a related factor, based on NANDA-I diagnostic
terminology. Most health promotion diagnoses do not have established related factors based on NANDA-I; their
use is optional. Wellness diagnoses are not one of the types of NANDA-I diagnoses.
A nurse interviewed and conducted a physical examination of a patient. Among the assessment data the
nurse gathered were an increased respiratory rate, the patient reporting difficulty breathing while lying flat,
and pursed-lip breathing. This data set is an example of:
A. Collaborative data set.
B. Diagnostic label.
C. Related factors.
D. Data cluster.
D
A data cluster is a set of cues (i.e., the signs or symptoms gathered during assessment).
A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing
diagnosis is Diarrhea related to intestinal colitis. For which of the following reasons is this an incorrectly
stated diagnostic statement?
A. Identifying the clinical sign instead of an etiology
B. Identifying a diagnosis on the basis of prejudicial judgment
C. Identifying the diagnostic study rather than a problem caused by the diagnostic study
D. Identifying the medical diagnosis instead of the patient's response to the diagnosis.
D
Intestinal colitis is a medical diagnosis. The related factor in a nursing diagnostic statement is always within the
,domain of nursing practice and a condition that responds to nursing interventions. Nursing interventions do not
change a medical diagnosis.
A nurse is assigned to a new patient admitted to the nursing unit following admission through the
emergency department. The nurse collects a nursing history and interviews the patient. What are the steps
for making a nursing diagnosis in the correct order, beginning with the first step?
1. Considers context of patient's health problem and selects a related factor
2. Reviews assessment data, noting objective and subjective clinical information
3. Clusters clinical cues that form a pattern
4. Chooses diagnostic label
A. 2, 3, 4, 1
B. 3, 2, 4, 1
C. 2, 3, 1, 4
D. 1, 4, 3, 2
A
This is the correct steps for making a nursing diagnosis.
A nursing student reports to a lead charge nurse that his assigned patient seems to be less alert and his
blood pressure is lower, dropping from 140/80 to 110/60. The nursing student states, "I believe this is a
nursing diagnosis of Deficient Fluid Volume." The lead charge nurse immediately goes to the patient's
room with the student to assess the patient's orientation, heart rate, skin turgor, and urine output for last 8
hours. The lead charge nurse suspects that the student has made which type of diagnostic error?
A. Insufficient cluster of cues
B. Disorganization
C. Insufficient number of cues
D. Evidence that another diagnosis is more likely
C
It is likely the charge nurse suspects that the student has not collected enough cues to support the diagnosis. A
change in blood pressure and mental status changes are significant findings that can be attributed to fluid volume
excess and other diagnoses. The recommendation of the symptom cluster by the registered nurse would allow
the student to have sufficient data to confirm a deficient fluid volume.
,A nurse in a mother-baby clinic learns that a 16-year-old has given birth to her first child and has not been
to a well-baby class yet. The nurse's assessment reveals that the infant cries when breastfeeding and has
difficulty latching on to the nipple. The infant has not gained weight over the last 2 weeks. The nurse
identifies the patient's nursing diagnosis as Ineffective Breastfeeding. Which of the following is the best
"related to" factor?
A. Infant crying at breast
B. Infant unable to latch on to breast correctly
C. Mother's deficient knowledge
D. Lack of infant weight gain
C
In this scenario the related factor is the mother's deficient knowledge. A related factor is a condition, historical
factor, or etiology that gives a context for the defining characteristics, in this case the infant crying, inability to
latch on to breast, and absent weight gain.
A nurse assesses a young woman who works part time but also cares for her mother at home. The nurse
reviews clusters of data that include the patient's report of frequent awakenings at night, reduced ability to
think clearly at work, and a sense of not feeling well rested. Which of the following diagnoses is in the
correct PES format?
A. Disturbed Sleep Pattern evidenced by frequent awakening
B. Disturbed Sleep Pattern related to family caregiving responsibilities
C. Disturbed Sleep Pattern related to need to improve sleep habits
D. Disturbed Sleep Pattern related to caregiving responsibilities as evidenced by frequent awakening and
not feeling rested
D
A nursing diagnosis in a PES format includes the diagnostic label, related factor, and the defining characteristics
by which the diagnosis is evidenced. The second nursing diagnosis is the correct format in the two-part format for
writing a diagnosis. The first diagnosis has no related factor. The third diagnosis is an error, using a goal as a
related factor.
A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient.
The student has assessed that the patient is undergoing radiation treatment and has had liquid stool and
the skin is clean and intact; therefore she selects the nursing diagnosis Impaired Skin Integrity. The faculty
member explains that the student has made a diagnostic error for which of the following reasons?
, A. Incorrect clustering
B. Wrong diagnostic label
C. Condition is a collaborative problem.
D. Premature closure of clusters
B
The more appropriate nursing diagnosis for this patient would be Risk for Impaired Skin Integrity because the
patient's skin is clean and intact. A risk nursing diagnosis is appropriate because the patient has two risk factors,
radiation and secretions on the skin.
Review the following problem-focused nursing diagnoses and identify the diagnoses that are stated
correctly. (Select all that apply.)
A. Impaired Skin Integrity related to physical immobility
B. Fatigue related to heart disease
C. Nausea related to gastric distention
D. Need for improved Oral Mucosa Integrity related to inflamed mucosa
E. Risk for Infection related to surgery
A, C
The related factors in diagnoses "Fatigue related to heart disease" and "Need for improved oral mucosa integrity
related to inflamed mucosa" are incorrect. The related factor of a medical diagnosis (in Fatigue related to heart
disease) cannot be corrected through nursing intervention. In "Need for improved oral mucosa integrity related to
inflamed mucosa" there is no diagnosis, but instead a goal of care. "Risk for infection related to surgery" is
incorrect; risk nursing diagnoses do not have defining characteristics or related factors because they have not
occurred yet.
A nurse reviews data gathered regarding a patient's ability to cope with loss. The nurse compares the
defining characteristics for Ineffective Coping with those for Readiness for Enhanced Coping and selects
Ineffective Coping as the correct diagnosis. This is an example of the nurse avoiding an error in: (Select all
that apply.)
A. Data collection.
B. Data clustering.
C. Data interpretation.
D. Making a diagnostic statement.
E. Goal setting.
