CHAPTER 7: Fundamentals of Nursing, 2nd Edition – Active Learning for Collaborative Practice by Yoost & Crawford

Fundamentals of Nursing, 2nd Edition – Active Learning for Collaborative Practice by Yoost & Crawford Chapter 7: Nursing Diagnosis Multiple Choice Questions 1. After completing a health and physical assessment on a patient admitted with a fractured pelvis, which task should the nurse perform next in the nursing process? A. Analyze and cluster the assessment information. B. Formulate a Nursing diagnosis addressing actual issues. C. Determine the need for potential Nursing diagnoses. D. Create health promotion diagnoses for the patient. Answer: A Explanation: Nursing diagnosis is the second step of the nursing process, requiring analysis and clustering of assessment data before formulating diagnoses. This systematic approach ensures accurate identification of patient needs. Why Other Options Are Wrong: B is premature before data analysis. C and D are subsequent steps after clustering data. 2. After a community nursing session on tuberculosis risks, patients request additional web resources. Which type of nursing diagnosis should the nurse include in the community care plan? A. Risk B. Actual C. Health-promotion D. Potential Answer: C Explanation: Health-promotion diagnoses apply when patients express interest in improving health behaviors, such as seeking additional education about TB prevention. Why Other Options Are Wrong: A addresses potential vulnerabilities. B identifies existing problems. D is not a valid diagnosis type. 3. Which diagnosis written on a care plan for a patient with pericarditis indicates a need for further instruction about nursing versus medical diagnoses? A. Pericarditis B. Acute pain C. Anxiety D. Activity intolerance Answer: A Explanation: Pericarditis is a medical diagnosis (inflammation of the pericardium), while nursing diagnoses focus on patient responses like pain or activity limitations. Why Other Options Are Wrong: B, C, and D are valid nursing diagnoses addressing patient responses to the medical condition. 4. A nurse is concerned that an experimental leukemia drug may cause low platelets and intestinal bleeding. Which nursing diagnosis type addresses this concern? A. Risk B. Actual C. Health-promotion D. Medical diagnosis Answer: A Explanation: Risk diagnoses apply when patients are vulnerable to potential problems, such as bleeding due to drug side effects. Why Other Options Are Wrong: B would be used if bleeding were already occurring. C relates to health improvement. D identifies diseases, not nursing concerns. 5. Which nursing diagnosis for a muscular dystrophy patient indicates a need for further instruction in constructing diagnostic statements? A. Constipation related to immobility as manifested by hard, dry stool. B. Activity intolerance related to weakness evidenced by fatigue. C. Impaired self-feeding related to fatigue as manifested by inability to open containers. D. Impaired airway clearance related to muscle weakness. Answer: D Explanation: This risk diagnosis lacks required defining characteristics (e.g., "as evidenced by" data), making it incomplete. Why Other Options Are Wrong: A, B, and C follow correct three-part (actual) or two-part (risk) statement structures. 6. In the diagnosis "Acute pain related to pressure on lumbar spinal nerves as evidenced by pain level of 9," what is the etiology? A. Patient verbalizations of pain B. Acute pain C. Pressure on lumbar spinal nerves D. Grimacing when walking Answer: C Explanation: The etiology (related factor) is the underlying cause of the problem—here, nerve pressure causing pain. Why Other Options Are Wrong: A and D are defining characteristics. B is the diagnosis label. 7. For a bedridden patient with blood clots who normally exercises regularly, which constipation diagnosis is accurate? A. Constipation related to bed rest as manifested by hard, dry stools. B. Constipation resulting from reduced circulation manifested by anxiety. C. Risk for constipation related to immobility as manifested by verbal complaint. D. Risk for constipation related to insufficient physical activity. Answer: D Explanation: This risk diagnosis correctly identifies inactivity as a vulnerability, without requiring current symptoms. Why Other Options Are Wrong: A assumes constipation exists already. B links unrelated factors. C mislabels a risk diagnosis as actual. 8. Which statement about health-promotion diagnoses indicates correct understanding? A. "The defining characteristics will include the patient's willingness to get better." B. "The risk factors are only psychological in nature, not physical." C. "The health-promotion diagnostic statement is composed of three parts." D. "An example is ineffective community coping." Answer: A Explanation: Health-promotion diagnoses focus on patient readiness for positive behavior change, reflected in defining characteristics. Why Other Options Are Wrong: B incorrectly limits risk factors. C is wrong—these diagnoses have two parts. D describes an actual diagnosis. 9. When reviewing assessment findings for a patient with bradycardia, dizziness, and low oxygen saturation, what should the nurse do next? A. Exclude all subjective data in favor of objective data. B. Focus on data gathered during the physical assessment. C. Evaluate the data looking for patterns and related data. D. Dismiss family members' input as "hearsay." Answer: C Explanation: Clustering related data (e.g., linking bradycardia with dizziness) is essential for accurate diagnosis formulation. Why Other Options Are Wrong: A, B, and D disregard valuable subjective or family input needed for holistic care. 10. For a dehydrated patient with hypotension, tachycardia, and confusion, which information should the nurse consider when choosing a diagnostic label? A. Blood pressure, pulse rate B. Blood pressure, pulse rate, blood volume C. Blood pressure, pulse rate, blood volume, mental status D. Blood pressure, pulse rate, blood volume, mental status, dehydration Answer: D Explanation: Comprehensive diagnosis requires integrating all assessment data, including medical history (dehydration) and symptoms. Why Other Options Are Wrong: A-C omit critical data needed to understand the full clinical picture. 11. Which cluster of symptoms (dry skin, brittle nails, weight gain, constipation) is most relevant for a patient with suspected hypothyroidism? A. Prolonged menstruation, constipation B. Dry skin, brittle nails, weight gain C. Tired, cold, thinning hair D. Constipation, weight gain Answer: D Explanation: Constipation and weight gain are classic hypothyroidism symptoms with a common metabolic etiology. Why Other Options Are Wrong: A combines unrelated systems. B and C include integumentary changes less specific to thyroid dysfunction. 12. A nurse assumes a hypertensive patient isn't taking medications due to cost and chooses "lack of knowledge" as a diagnosis. This exemplifies what error? A. Clustering unrelated data B. Selecting erroneous data C. Using medical diagnoses D. Identifying multiple problems in one statement Answer: A Explanation: The nurse clustered blood pressure results with cost concerns without verifying medication adherence first. Why Other Options Are Wrong: B would involve using incorrect data. C and D are unrelated to this scenario. 13. For a patient with gastritis, abdominal pain, nausea, restless legs, and urinary retention, what is the correct problem statement? A. Gastritis related to inflammation. B. Alterations in comfort and ability to void. C. Abdominal pain and nausea related to inflammation. D. Alteration in comfort related to restless leg syndrome and inflammation. Answer: C Explanation: This clusters related GI symptoms (pain/nausea) with their likely cause (inflammation), excluding unrelated urinary/leg issues. Why Other Options Are Wrong: A uses a medical diagnosis. B and D combine unrelated problems. 14. Which submitted nursing diagnostic statement is written incorrectly? A. Difficulty coping related to inadequate support systems as evidenced by patient's verbalization. B. Activity intolerance related to immobility as manifested by shortness of breath. C. Impaired sleep and lack of knowledge related to stress as evidenced by difficulty sleeping. D. Impaired self-feeding related to extremity weakness as manifested by inability to use utensils. Answer: C Explanation: This incorrectly combines two diagnoses ("impaired sleep" and "lack of knowledge") in one statement. Why Other Options Are Wrong: A, B, and D follow proper single-diagnosis structures. 15. When creating a nursing diagnosis, what is the basis for the related factor? A. It should be based on the medical diagnosis. B. It is unrelated to the pathophysiology causing the problem. C. It is the underlying etiology of the patient's situation. D. It does not reflect the nurse's understanding of pathophysiology. Answer: C Explanation: Related factors identify the root cause (e.g., "immobility" for constipation) rather than medical diagnoses. Why Other Options Are Wrong: A contradicts nursing diagnosis principles. B and D misrepresent the purpose of related factors. 16. As the primary caregiver for a complex patient, what is the nurse's ultimate responsibility? A. Assess patient needs and progress continually. B. Delegate to others who operate independently. C. Provide total care after getting direction from others. D. Hold the patient responsible for failure or success. Answer: A Explanation: Nurses retain accountability for ongoing assessment, even when delegating tasks to other team members. Why Other Options Are Wrong: B ignores needed supervision. C undervalues nurse autonomy. D is ethically inappropriate. 17. What key concept does nursing diagnosis facilitate when communicating patient needs? A. Changes in patient condition do not require diagnosis updates. B. Use of language difficult for legislators to interpret. C. Communication with nurses but not other disciplines. D. Clear communication of needs and professional accountability. Answer: D Explanation: Standardized nursing diagnoses promote clear interdisciplinary communication and demonstrate nursing's unique role. Why Other Options Are Wrong: A is false—diagnoses should evolve with patient conditions. B and C contradict the purpose of unified language. 18. For a stroke patient with right-sided weakness and slurred speech, what is the etiology of gait problems? A. Lack of muscle motor movement B. Decreased sensation to touch C. Inability to speak clearly D. Pain in back of head Answer: A Explanation: Gait imbalance stems from motor deficits (weakness), not sensory or speech issues. Why Other Options Are Wrong: B, C, and D are unrelated to mobility impairment. 19. When planning care for a malnourished, immobile patient with a pressure ulcer and suspected depression, what should the nurse do? A. Develop multiple nursing diagnoses. B. Develop only one focused diagnosis. C. Focus solely on physical issues. D. Address only psychological needs. Answer: A Explanation: Complex patients often require multiple diagnoses (e.g., impaired skin integrity, activity intolerance, situational depression). Why Other Options Are Wrong: B oversimplifies care. C and D neglect holistic needs. Multiple Response Questions 20. For a patient with bone pain from an infected wound, which diagnoses reflect understanding of nursing versus medical diagnoses? (Select all that apply.) A. Acute pain B. Risk for impaired walking C. Ineffective bone tissue perfusion D. Osteomyelitis E. Infection Answer: A, B, C Explanation: These are nursing diagnoses addressing pain, mobility risk, and perfusion due to the medical condition (osteomyelitis). Why Other Options Are Wrong: D and E are medical diagnoses, not nursing responses. 21. Which nursing diagnoses for a cocaine overdose patient are correctly structured? (Select all that apply.) A. Impaired breathing related to drug effect on the respiratory center. B. Risk for injury related to hallucinations. C. Insomnia D. Impaired socialization related to excessive stimulation as evidenced by unintelligible speech. E. Powerlessness Answer: B, D Explanation: B is a proper risk diagnosis; D includes all required parts (label, etiology, manifestations). Why Other Options Are Wrong: A lacks manifestations. C is a medical term. E is incomplete. 22. For a patient with chest pain and fear of familial heart disease history, which diagnoses apply? (Select all that apply.) A. Acute pain B. Fear C. Risk for aspiration D. Risk for infection E. Impaired role performance Answer: A, B Explanation: Pain and fear are directly supported by assessment data (chest pain, verbalized anxiety). Why Other Options Are Wrong: C, D, and E lack evidence in the scenario. 23. Why is accurate nursing diagnosis selection critical? (Select all that apply.) A. Patient satisfaction B. Positive patient outcomes C. Quality patient care D. Help develop standardized care plans E. Determine appropriate interventions Answer: A, B, C, E Explanation: Accurate diagnoses directly impact care quality, outcomes, satisfaction, and intervention selection. Why Other Options Are Wrong: D is incorrect—diagnoses guide individualized, not standardized, plans. 24. Which factors in a health assessment would prompt a suicide watch order? (Select all that apply.) A. Threats of killing oneself B. Chronic pain C. History of prior suicide attempt D. Loneliness E. Stable heart rhythm Answer: A, B, C, D Explanation: These are known suicide risk factors (verbal threats, pain, isolation, past attempts). Why Other Options Are Wrong: E is irrelevant to suicide risk assessment.