Afteruassessinguaupuatient,
f uaunurseudevelopsuaustandarduformalunursingudiagn osis.uWhatuisutheurationale
orutheunurse’suacti ons?
1
a. Touformuaulanguageuthatucanubeuencodeduonlyubyunurse
s
b. Toudistinguishuthe nurse’suroleufromutheuphysician’surol
e
, c. Toudevelopuclinicalujudgmentubaseduonuother’suintuition
d. Touhelpunursesufocusuonutheuscopeuofumedicalupractice
ANS:uB
Theustandarduformalunursingudiagnosisuservesuseveralupurposes.uNursingudiagnosesudistinguishutheunurse’su
roleufromuthatuofutheuphysician/healthucareuprovideruanduhelpunursesufocusuonutheuscopeuofunursingupracticeu
(notumedical)uwhileufosteringutheudevelopmentuofunursinguknowledge.uAunursingudiagnosisuprovidesutheupr
eciseudefinitionuthatugivesuallumembersuofutheuhealthucareuteamuaucommonulanguageuforuunderstandingutheu
patient’suneeds.uAudiagnosisuisuauclinicalujudgmentubaseduonuinformation.
2. Whichudiagnosisuwillutheunurseudocumentuinuaupatient’sucareuplanuthatuisuNANDA-Iuapproved?
a. Soreuthroat
b. Acuteupain
c. Sleepuapnea
d. Heartufailure
ANS:uB
AcuteupainuisutheuonlyuNANDA-
Iuapprovedudiagnosisulisted.uSleepuapneauanduheartufailureuareumedicaludiagnoses,uandusoreuthroatui
susubjectiveudata.
3. Aunurseudevelopsuaunursingudiagnosticustatementuforuaupatientuwithuaumedicaludiagnosisuofu
pneumoniauwithuchestux-
rayuresultsuofulowerulobeuinfiltrates.uWhichunursingudiagnosisudidutheunurse
write?
a. Ineffectiveubreathingupatternurelatedutoupneumonia
b. Riskuforuinfectionurelatedutouchestux-rayuprocedure
c. Riskuforudeficientufluiduvolumeurelatedutoudehydration
Impairedugasuexchangeurelatedutoualveolar-capillaryumembrane
d. changes
ANS:uD
Theurelatedutoufactoruofualveolar-
capillaryumembraneuchangesuisuaccuratelyuwrittenubecauseuituisuaupatienturesponseutoutheudiseaseuprocessuofu
pneumoniauthatutheunurseucanutreat.uTheurelatedutoufactorushouldubeutheucauseuofutheuproblemu(nursingudiagn
osis)uthatuaunurseucanuaddress.uTheurelatedutoufactorsuofudehydrationuandupneumoniauareuallumedicaludiagno
sesuthatutheunurseucannotuchange.uAudiagnosticutestuoruauchronicudysfunctionuisunotuanuetiologyuoruauconditio
nuthatuaunursinguinterventionuisuableutoutreat.
4. Theunurseuisureviewinguaupatient’suplanuofucare,uwhichuincludesutheunursingudiagnosticustatem
ent,uImpaireduphysicalumobilityurelatedutoutibialufractureuasuevidencedubyupatient’suinabilityutouambul
ate.uWhichupartuofutheudiagnosticustatementudoesutheunurseuneedutourevise?
a. Etiology
b. Nursingudiagnosis
c. Collaborativeu problem
d. Definingucharacteristic
ANS:uA 2
Theuetiology,uorurelatedutoufactor,uofutibialufractureuisuaumedicaludiagnosisuanduneedsutoubeurevised.uThe
, nursingudiagnosisuisuappropriateubecauseutheupatientuisuunableutouambulate.uAucollaborativeuproblemuisuanua
ctualuorupotentialuphysiologicalucomplicationuthatunursesumonitorutoudetectutheuonsetuofuchangesuinuaupatien
t’suhealthustatus;uthereuisunoucollaborativeuproblemulisted.uTheudefiningucharacteristicu(subjectiveuanduobject
iveudatauthatusupportutheudiagnosis)uisuappropriateuforuImpaireduphysicalumobility.
5. Aunurseuisuusinguassessmentudataugathereduaboutuaupatientuanducombiningucriticaluthinking
toudevelopuaunursingudiagnosis.uWhatuisutheunurseudoing?
a. Assigninguclinicalucues
b. Definingucharacteristics
c. Diagnosticureasoning
d. Diagnosticulabeling
ANS:uC
Diagnosticureasoninguisudefineduasuauprocessuofuusingutheuassessmentudataugathereduaboutuaupatientutoulo
gicallyuexplainuauclinicalujudgment,uinuthisucaseuaunursingudiagnosis.uDefiningucharacteristicsuareuassess
mentufindingsuthatusupportutheunursingudiagnosis.uDefiningucharacteristicsuareutheusubjectiveuanduobjecti
veuclinicalucues,uwhichuaunurseugathersuintentionallyuanduunintentionally.uTheunurseuorganizesualluofutheu
patient’sudatauintoumeaningfuluanduusableudatauclusters,uwhichuleadutouaudiagnosticuconclusion.
Diagnosticulabelinguisusimplyutheunameuofutheudiagnosis.
6. Aupatientupresentsutoutheuemergencyudepartmentufollowinguaumotoruvehicleucrashuandusuffer
suaurightufemurufracture.uTheuleguisustabilizeduinuaufullulegucast.uOtherwise,utheupatientuhasunouother
umajoruinjuries,uisuinugooduhealth,uandureportsuonlyumoderateudiscomfort.uWhichuisutheumostuperti
nentunursingudiagnosisutheunurseuwilluincludeuinutheuplanuofucare?
a. Posttraumausyndrome
b. Constipation
c. Acuteupain
d. Anxiety
ANS:uC
Baseduonutheuassessmentudatauprovided,utheuonlyusupportiveuevidenceuforuoneuofutheudiagnosisuoptionsuisu“
Reportsuonlyumoderateudiscomfort,”uwhichuwouldusupportuAcuteupain.uNousupportiveuevidenceuisuprovided
uforuanyuofutheuotherudiagnoses.uTheupatientumayuindeedudevelopusignsuorusymptomsuofutheuotheruproblems,u
butusupportiveudatauareupresentlyulackinguinutheuprovideduinformation.
7. Theunurseuisureviewinguaupatient’sudatabaseuforusignificantuchangesuandudiscoversuthatutheup
atientuhasunotuvoideduinuoveru8uhours.uTheupatient’sukidneyufunctionulaburesultsuareuabnormal,uandu
theupatient’suoraluintakeuhasusignificantlyudecreasedusinceupreviousushifts.uWhichustepuofutheunursin
g
processushouldutheunurseuproceedutouafteruthisureview?
a. Diagnosis
b. Planning
c. Implementation
d. Evaluation
3
ANS:uA