Chapter 12- Nursing Diagnosis.rtf (42 kb) Nursing School Test Banks

 

1.

Which of the following assessment findings would support the nursing diagnosis of acute pain? Select all that apply.

A)

Patient had an abdominal hysterectomy 1 day ago.

B)

Patient is crying in pain about 20 minutes before her pain medicine is due.

C)

Patient has a history of osteoarthritis.

D)

Patient had back surgery 2 years ago and expresses the need for ibuprofen on most days.

E)

Patient is a heavy cigarette smoker.

Ans:

A, B

Feedback:

The patient crying in pain one day after surgery would be expected and lead to a nursing diagnosis of acute pain. Although the patient likely experiences pain from the past back surgery and osteoarthritis, it would not support the diagnosis of acute pain. The smoking history does not support the diagnosis.

2.

What is the process of gathering and clustering data to draw inferences and propose a diagnosis?

A)

Critical thinking

B)

Analytical reasoning

C)

Diagnostic reasoning

D)

Recollection

Ans:

C

Feedback:

Diagnostic reasoning is the process of gathering and clustering data to draw inferences and propose diagnoses.

3.

The purpose of establishing a nursing diagnosis is to

A)

Describe a functional health problem

B)

Collaborate with the physician

C)

Identify medical problems

D)

Meet accreditation criteria

Ans:

A

Feedback:

Establishment of a nursing diagnosis reflects the synthesis of data gathered during a nursing assessment. Gordon suggested a framework for organizing nursing diagnoses based on functional health, thus offering a convenient way to cluster similar diagnoses.

4.

Why is coding important when writing a nursing diagnosis?

A)

Enhances the professionalism of the nursing process

B)

Allows for direct reimbursement for nurses

C)

Evaluates the diagnostic statement for accuracy

D)

Provides legal characteristics for licensure

Ans:

B

Feedback:

Coding of nursing diagnoses in computerized systems allows direct reimbursement of nurses.

5.

Which of the following statements appropriately identifies an at-risk nursing diagnosis for a 78-year-old woman who is confined to bed?

A)

Ineffective airway clearance related to bed rest

B)

Immobility related confinement to bed

C)

Potential for pneumonia related to inactivity

D)

Risk for impaired skin integrity related to bed rest

Ans:

D

Feedback:

An at-risk nursing diagnosis, as defined by NANDA, describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community.

6.

A nurse sees the patient grimace and documents that the patient is in pain, without interviewing the patient to obtain further cues. The nurse has

A)

Impaired cluster interpretation

B)

A lack of cues or premature closure

C)

Ineffective database

D)

Inaccurate evaluation

Ans:

B

Feedback:

The lack of adequate cues is called premature closure.

7.

The act of analyzing and synthesizing cues requires

A)

critical thinking

B)

certification

C)

advanced practice

D)

attendance at NANDA

Ans:

A

Feedback:

During clustering, critical thinking is used to analyze and synthesize cues.

8.

A patient is experiencing shortness of breath, lethargy, and cyanosis. These three cues provides organization or

A)

Categorizing

B)

Diagnosing

C)

Grouping

D)

Clustering

Ans:

D

Feedback:

Cue clustering brings together cues that if viewed separately would not convey the same meaning.

9.

One major requirement of a nursing diagnosis is that it focuses on a problem that is

A)

Established by the physician

B)

Based on the patients pathophysiology

C)

Legally treatable by registered nurses

D)

Included within the diagnosis-related group

Ans:

C

Feedback:

Registered nurses are educated and licensed to make nursing diagnoses. As such, they have a duty to identify and plan care for patients based on them.

10.

What information provides the nurse with accuracy when developing a nursing diagnosis?

A)

A set of lab values

B)

Abnormal diagnostic tests

C)

A set of clinical cues

D)

Specific nursing interventions

Ans:

C

Feedback:

Each piece of patient information is considered a clinical cue; a set of clinical cues forms a cluster that is present if the diagnosis is accurate.

11.

What is meant by impaired state of equilibrium?

A)

It describes the patients condition

B)

It is common terminology

C)

It is a nursing diagnosis

D)

It assists in planning care

Ans:

A

Feedback:

Descriptors such as impaired state of equilibrium describe changes in condition, state of the patient, or some qualification of the specific nursing diagnosis.

12.

What gives additional meaning to a nursing diagnosis?

A)

Composition

B)

Descriptors

C)

Dysfunction

D)

Qualifications

Ans:

B

Feedback:

Descriptors are words used to give additional meaning to a nursing diagnosis.

13.

What does the nursing diagnosis represent?

A)

Symptoms

B)

Signs

C)

Cues

D)

Maladaptation

Ans:

C

Feedback:

Each nursing diagnosis represents a pattern of related patient cues.

14.

In the development of a nursing diagnosis for a patient who has cachexia and decreased weight, what would be an appropriate nursing diagnosis?

A)

Anorexia nervosa and bulimia

B)

Lack of adequate nutrition related to decreased calories

C)

Weight loss related to abdominal discomfort

D)

Imbalanced nutrition: less than body requirements

Ans:

D

Feedback:

Another common mistake is to write Lack of adequate nutrition as the nursing diagnosis. The most appropriate nursing diagnosis would be Imbalanced Nutrition: Less than Body Requirements.

15.

Nursing diagnoses that require physician-prescribed and nurse-prescribed actions would be

A)

Independent health problems

B)

Collaborative health problems

C)

Physician-developed problems

D)

Interdisciplinary health problems

Ans:

B

Feedback:

If problems require physician-prescribed and nurse-prescribed actions, they are collaborative health problems.

16.

Which of the following is classified as a nursing diagnosis?

A)

Esophageal cancer

B)

Cholecystitis

C)

Grieving

D)

Pneumonia

Ans:

C

Feedback:

Grieving is a nursing diagnosis per the latest NANDA Taxonomy. The other choices are medical diagnoses.

17.

The nursing diagnosis taxonomy provides nursing with

A)

Legal information

B)

Common language

C)

Discharge planning

D)

Evaluative care

Ans:

B

Feedback:

Professions require a sound scientific base; the nursing process is nursings scientific base. To achieve this scientific foundation, nursing requires a taxonomy, or classification system, to provide a structure for nursing practice.

18.

What is the nurse accountable for according to the state nurse practice act?

A)

Continuing education

B)

Nursing diagnoses

C)

Prescribing medications

D)

Mentoring other nurses

Ans:

B

Feedback:

State nurse practice acts have included diagnoses as part of the domain of nursing practice for which nurses are held accountable.

19.

The purpose of establishing a nursing diagnosis is to

A)

Describe a functional health problem

B)

Collaborate with physicians

C)

Identify medical problems

D)

Meet accreditation criteria

Ans:

A

Feedback:

The purpose of the nursing diagnosis is to synthesize data gathered during the nursing assessment.

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