NUR 231 Chapter 17 Nursing Diagnosis Review Questions

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Review the following problem-focused nursing diagnoses and identify the diagnosis that are stated correctly. (Select all that apply)
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– Impaired skin integrity related to physical immobility – Nausea related to gastric distension
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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)
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– Date collection – Data interpenetration
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The nursing diagnosis Impaired Parenting related to mother’s developmental delay is an example of:
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problem-focused nursing diagnosis
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A nurse interviewing 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 laying flat, and pursed-lip breathing. This data set is an example of:
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data cluster
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In which of the following examples are nurses making diagnostic errors? (select all that apply)
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– the nurse who observes a patient wincing and holding his left side and gathers no additional assessment data – the nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping – the nurse who makes a diagnosis of Ineffective Airway Clearance related pneumonia
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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 the an incorrectly stated diagnostic statement?
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Identifying the medical diagnosis instead of the patient’s response to the diagnosis
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A nurse is assigned to a new patient admitted to the nursing unit following admissions through the emergency department. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order, beginning with the first step.
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– Reviews assessment data, noting objective and subjective clinical information – clusters clinical cues that form a pattern -Chooses diagnostic label – Considers context of patient’s health problem and selects a related factor
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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?
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Insufficient number or cues
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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?
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Mother’s deficient knowledge
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A nurse is getting ready to assess a patient in a neighborhood community clinic. He was newly diagnosed with diabetes just a month ago. He has other health problems and a history of not being able to manage his health. Which of the following questions reflects the nurse’s cultural competence in making an accurate diagnosis (select all that apply)
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– How is your diabetic diet affecting you and your family? – What worries you the most about having diabetes – What do you believe will help you control your blood sugar?
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A nurse assesses a young women 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?
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Disturbed Sleep Pattern related to care giving responsibilities as evidenced by frequent awakening and not feeling rested
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A nursing student is working with a facility 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?
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wrong diagnostic label
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The use of standard formal nursing diagnostic statement serves several purposes in nursing practice, including which of the following? (select all that apply)
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– Defines a patient’s problem, giving members of the health care team a common language for understanding the patient’s needs – helps nurses focus on the scope of nursing practice – builds and expands nursing knowledge
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Which of the following nursing diagnoses is stated correctly? (select all that apply)
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– Sleep Deprivation related to sustained noisy environment – Ineffective Protection related to inadequate nutrition

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