NUR 216 health assessment EXAM 4 |
COMPLETE VERIFIED QUESTIONS &
ANSWERS GRADED A+ GUARANTEED
PASS (100% VERIFIED SOLUTIONS)
2025/2026 UPDATED VERSION
1. After an assessment, the nurse reviews the list of client problems. For which problems
should the nurse create nursing diagnoses?
a. The ones that the nurse is licensed to treat
b. The ones that address other health professionals' interventions
c. The ones that focus on the client's primary illness
d. The ones that have standardized care available
- Answer ✓✓a. The ones that the nurse is licensed to treat
Nursing diagnosis fulfills that need and help the scope of nursing practice by describing
conditions that the nurse can independently treat.
2. A client comes to the clinic seeking information and education regarding healthy lifestyles
and eating habits. Which type of diagnosis should the nurse select for this client?
a. Risk nursing diagnosis
b. Syndrome diagnosis
c. Wellness diagnosis
d. Actual diagnosis
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- Answer ✓✓Wellness diagnosis
A health promotion diagnosis relates to clients preparedness to implement behaviors to
improve their health condition
3. The graduate nurse is struggling with identifying cues from clustered data. What should the
nurse use to recognize data patterns and cues?
a. Depend on knowledge gained from peers' experiences.
b. Work with seasoned and experienced nurses and learn from them.
c. Take assessment notes and utilize information from textbooks for comparison.
d. Know that this will take time, and experience is the best teacher.
- Answer ✓✓c. Take assessment notes and utilize information from textbooks for
comparison.The nurse may cluster data inductively by combining data from different
assessment areas to form a pattern
4. The nurse has formulated the diagnosis of Activity intolerance, related to weakness and
debilitation, manifested by reports of fatigue after any physical activity. What is the defining
characteristic of this label?
a. Activity intolerance - P
b. Weakness and debilitation - E
c. Reports of fatigue - S
d. Physical activity
- Answer ✓✓c. Reports of fatigue - S
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Cue for defining characteristics is symptoms and signs - (manifested by or evidenced by)
indicates it is a S part
5. The nurse identifies the diagnosis of Anxiety, related to unfamiliarity of disease process,
manifested by restlessness and tachycardia for a client newly diagnosed with pancreatic
cancer. What is the etiology of this diagnosis?
a. Unfamiliarity of disease process
b. Anxiety
c. Restlessness
d. Tachycardia
- Answer ✓✓a. Unfamiliarity of disease process
6. The nurse is using the PES model to write a nursing diagnosis. Which nursing diagnoses
demonstrate that the nurse used this model appropriately? (Select all that apply.)
a. Ineffective coping related to depression as evidenced by suicide attempt
b. Noncompliance (DASH diet) related to denial of having disease
c. Risk for infection related to recent surgery
d. Nutrition less than adequate related to anxiety as evidenced by weight loss of 10 pounds
e. Ineffective Breathing Pattern as evidenced by cyanotic lips
- Answer ✓✓a. Ineffective coping related to depression as evidenced by suicide attempt
d. Nutrition less than adequate related to anxiety as evidenced by weight loss of 10 pounds
A and D fits with PES model, A- P ineffective coping E - depression S- suicide attempt
D - P nutrition less than adequate E - anxiety S - Weight loss of 10 pounds
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7. The nurse is reviewing information about the formulation of nursing diagnoses. What
should the nurse identify as the area in which nursing diagnoses differ from medical
diagnoses and collaborative problems?
a. Mental status of the client
b. Chronic nature of the illness
c. Nursing care focus
d. Prognosis
- Answer ✓✓c. Nursing care focus
Nursing diagnoses differ from medical diagnoses and collaborative problems in a way that it is
more of a human to human treatment rather than defining the symptoms in a medical term
8. The nurse formulates the nursing diagnosis of Acute pain, related to tissue damage,
secondary to infarction, manifested by pallor, client report, and shallow, rapid breathing for a
client experiencing an acute myocardial infarction. Which collaborative action would be
appropriate for this client?
a. Provide a calm, quiet atmosphere in the client's room.
b. Administer pain medication.
c. Educate the client and family regarding treatment and therapies.
d. Monitor for changes in the client's condition.
- Answer ✓✓b. Administer pain medication.
B requires physician's order - can't give pain medication without the order - that's why it is
collaborative action. We can do other stuff alone as a nurse
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