Nursing Diagnosis Review Questions

question

Review the following problem-focused nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.) 1. Impaired Skin Integrity related to physical immobility 2. Fatigue related to heart disease 3. Nausea related to gastric distention 4. Need for improved Oral Mucosa Integrity related to inflamed mucosa 5. Risk for Infection related to surgery
answer

1, 3 Impaired skin integrity related to physical immobility Nausea related to gastric distention
question

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.) 1. Data collection. 2. Data clustering. 3. Data interpretation. 4. Making a diagnostic statement. 5. Goal setting.
answer

1, 3 Data collection Data interpretation
question

The nursing diagnosis Impaired Parenting related to mother’s developmental delay is an example of a(n): 1. Risk nursing diagnosis. 2. Problem-focused nursing diagnosis. 3. Health promotion nursing diagnosis. 4. Wellness nursing diagnosis.
answer

2 Problem-focused nursing diagnosis
question

A nurse interviewed 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 lying flat, and pursed-lip breathing. This data set is an example of: 1. Collaborative data set. 2. Diagnostic label. 3. Related factors. 4. Data cluster.
answer

4 Data cluster
question

In which of the following examples are nurses making diagnostic errors? (Select all that apply.) 1. The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data 2. The nurse who measures joint range of motion after the patient reports pain in the left elbow 3. The nurse who considers conflicting cues in deciding which diagnostic label to choose 4. The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping 5. The nurse who makes a diagnosis of Ineffective Airway Clearance related to pneumonia.
answer

1, 4, 5 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 to pneumonia
question

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 this an incorrectly stated diagnostic statement? 1. Identifying the clinical sign instead of an etiology 2. Identifying a diagnosis on the basis of prejudicial judgment 3. Identifying the diagnostic study rather than a problem caused by the diagnostic study 4. Identifying the medical diagnosis instead of the patient’s response to the diagnosis.
answer

4 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 admission 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. 1. Considers context of patient’s health problem and selects a related factor 2. Reviews assessment data, noting objective and subjective clinical information 3. Clusters clinical cues that form a pattern 4. Chooses diagnostic label
answer

2, 3, 4 Reviews assessment data, noting objective and subjective clinical information Clusters clinical cues that form a pattern Chooses diagnostic label
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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? 1. Insufficient cluster of cues 2. Disorganization 3. Insufficient number of cues 4. Evidence that another diagnosis is more likely
answer

3 Insufficient number of 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? 1. Infant crying at breast 2. Infant unable to latch on to breast correctly 3. Mother’s deficient knowledge 4. Lack of infant weight gain
answer

3 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.) 1. How is your diabetic diet affecting you and your family? 2. You seem to not want to follow health guidelines. Can you explain why? 3. What worries you the most about having diabetes? 4. What do you expect from us when you do not take your insulin as instructed? 5. What do you believe will help you control your blood sugar?
answer

1, 3, 5 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?
question

A nurse assesses a young woman 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? 1. Disturbed Sleep Pattern evidenced by frequent awakening 2. Disturbed Sleep Pattern related to family caregiving responsibilities 3. Disturbed Sleep Pattern related to need to improve sleep habits 4. Disturbed Sleep Pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested
answer

4 Disturbed sleep pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested
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A nursing student is working with a faculty 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? 1. Incorrect clustering 2. Wrong diagnostic label 3. Condition is a collaborative problem. 4. Premature closure of clusters
answer

2 Wrong diagnostic label
question

The use of standard formal nursing diagnostic statements serves several purposes in nursing practice, including which of the following? (Select all that apply.) 1. Defines a patient’s problem, giving members of the health care team a common language for understanding the patient’s needs 2. Allows physicians and allied health staff to communicate with nurses how they provide care among themselves 239 3. Helps nurses focus on the scope of nursing practice 4. Creates practice guidelines for collaborative health care activities 5. Builds and expands nursing knowledge
answer

1, 3, 5 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
question

Which of the following nursing diagnoses is stated correctly? (Select all that apply.) 1. Fluid Volume Excess related to heart failure 2. Sleep Deprivation related to sustained noisy environment 3. Impaired Bed Mobility related to postcardiac catheterization 4. Ineffective Protection related to inadequate nutrition 5. Diarrhea related to frequent, small, watery stools.
answer

2, 4 Sleep deprivation related to sustained noisy environment Ineffective protection related to inadequate nutrition

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