Chapter 17 Nursing Diagnosis Fundamentals of Nursing 11th Edition (Potter & Perry) 50 NCLEX-Style Exam Questions with Detailed Rationales

1. A nurse is assessing a patient and determines that the patient has insufficient resources to meet basic nutritional needs. Which type of nursing diagnosis does this represent? A. Risk diagnosis B. Actual diagnosis C. Wellness diagnosis D. Syndrome diagnosis Answer: B. Actual diagnosis Rationale: An actual nursing diagnosis identifies an existing problem validated by signs and symptoms. ________________________________________ 2. Which component is essential in formulating an accurate nursing diagnosis using NANDA-I taxonomy? A. Nursing interventions B. Physician orders C. Defining characteristics D. Outcomes identification Answer: C. Defining characteristics Rationale: Defining characteristics are observable cues/inferences that validate a specific nursing diagnosis. ________________________________________ 3. A patient tells the nurse, “I feel so hopeless.” The nurse identifies the diagnosis Hopelessness. Which NANDA-I component is being applied? A. Etiology B. Risk factor C. Problem statement D. Related factor Answer: C. Problem statement Rationale: The problem statement is the diagnostic label (e.g., Hopelessness) and identifies the patient's response. ________________________________________ 4. Which nursing diagnosis is correctly written according to NANDA-I guidelines? A. Pain related to surgery B. Risk for falls related to age C. Impaired mobility related to fractured leg as evidenced by inability to bear weight D. Diabetes related to insulin deficiency Answer: C. Impaired mobility related to fractured leg as evidenced by inability to bear weight Rationale: This example uses the PES format: Problem, Etiology, and Signs/Symptoms. ________________________________________ 5. The nurse identifies that a patient may develop pressure injuries due to immobility. What is the appropriate type of nursing diagnosis? A. Health promotion B. Actual C. Syndrome D. Risk Answer: D. Risk Rationale: A risk diagnosis applies when risk factors are present but no current symptoms exist. ________________________________________ 6. Which of the following is an example of a health promotion nursing diagnosis? A. Readiness for enhanced nutrition B. Risk for impaired skin integrity C. Ineffective airway clearance D. Chronic pain Answer: A. Readiness for enhanced nutrition Rationale: Health promotion diagnoses focus on the patient's motivation and desire to improve well-being. ________________________________________ 7. What should the nurse consider most when choosing a nursing diagnosis? A. Physician’s diagnosis B. Patient’s preferences C. Assessment data D. Nurse’s intuition Answer: C. Assessment data Rationale: Assessment data provides the foundation for choosing the correct nursing diagnosis. ________________________________________ 8. The “related to” part of a nursing diagnosis identifies: A. The evidence or symptoms B. The outcome goal C. The underlying cause D. The patient’s feelings Answer: C. The underlying cause Rationale: "Related to" connects the diagnosis to its etiology, explaining the contributing factors. ________________________________________ 9. Which of the following would be an example of a syndrome diagnosis? A. Acute pain B. Risk for disuse syndrome C. Chronic low self-esteem D. Post-trauma syndrome Answer: D. Post-trauma syndrome Rationale: A syndrome diagnosis includes a cluster of related nursing diagnoses often treated together. ________________________________________ 10. A nurse uses the PES format to write a nursing diagnosis. What does "E" stand for? A. Evaluation B. Etiology C. Environment D. Education Answer: B. Etiology Rationale: In the PES format: P = Problem, E = Etiology (cause), S = Signs/Symptoms. ________________________________________ 11. Why is it important for nursing diagnoses to be individualized to the patient? A. To follow legal guidelines B. To fit the care plan template C. To ensure reimbursement D. To provide patient-centered care Answer: D. To provide patient-centered care Rationale: Individualizing diagnoses ensures care is specific and relevant to the patient's condition. ________________________________________ 12. Which nursing diagnosis is most appropriate for a patient experiencing social withdrawal, low energy, and sleep disturbances? A. Risk for loneliness B. Chronic sorrow C. Depression D. Social isolation Answer: D. Social isolation Rationale: The signs described match the characteristics of social isolation per NANDA-I. ________________________________________ 13. How many parts does a risk nursing diagnosis contain in the NANDA-I format? A. One B. Two C. Three D. Four Answer: B. Two Rationale: Risk diagnoses include the problem and related risk factors—no signs or symptoms are present. ________________________________________ 14. A nurse writes: "Impaired skin integrity related to immobility as evidenced by reddened sacral area." What format is this? A. SOAP B. PIE C. PES D. DAR Answer: C. PES Rationale: This diagnosis includes the Problem, Etiology, and Signs/Symptoms. ________________________________________ 15. Which nursing diagnosis would be most appropriate for a client who has no disease but expresses interest in preventing diabetes? A. Risk for diabetes B. Knowledge deficit C. Readiness for enhanced knowledge D. Ineffective health maintenance Answer: C. Readiness for enhanced knowledge Rationale: The client expresses readiness for learning and health promotion, not an active problem. ________________________________________