Chapter 16: Nursing Diagnosis Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 6th Edition

MULTIPLE CHOICE

1. After completion of the client assessment, the nurse uses nursing diagnoses because they:

a.

Make all client problems become more quickly and easily resolved

b.

Assist the nurse to distinguish medical from nursing problems

c.

Are required for accreditation purposes

d.

Identify the domain and focus of nursing

ANS: d

d. After completing the client assessment, the nurse develops nursing diagnoses based on the data obtained. Nursing diagnoses distinguish the nurses role from that of the physician, and help nurses to focus on the role of nursing in client care.

a. Nursing diagnoses may facilitate communication among health professionals, but they do not necessarily make all client problems more quickly and easily resolved.

b. Medical problems are identified with medical diagnostic statements to treat a disease condition. Nursing diagnoses describe the clients actual or potential response to a health problem that the nurse is licensed and competent to treat. Nursing diagnoses distinguish the nurses role from that of the physician.

c. Although most state nurse practice acts include nursing diagnosis as part of the domain of nursing practice, nursing diagnoses are not required for accreditation purposes.

REF: Text Reference: p. 303

2. A 53-year-old client is seen at the clinic for a yearly physical examination. In evaluating the clients weight, the nurse also considers the age and height. This is an example of:

a.

Defining the client problem

b.

Recognizing gaps in data assessment

c.

Comparing data with normal health patterns

d.

Drawing conclusions about the clients response

ANS: c

c. The nurse used scientific knowledge and experience to analyze and interpret data collected about the client. This includes comparing the data with norms.

a. The nurse is comparing data to determine whether a problem exists. A problem has not yet been identified.

b. The nurse is not recognizing gaps in data assessment. An example of a gap in data assessment would be if the clients weight had not been measured.

d. The nurse has not drawn a conclusion about the clients response. The nurse must first compare the data with normal health problems to be able to come to a conclusion.

REF: Text Reference: p. 304

3. Nursing diagnoses meet specific criteria so they accurately reflect both the clients problem and the possible etiology involved. Of the following statements, which one is an example of an appropriately written nursing diagnosis?

a.

Acute pain related to left mastectomy

b.

Impaired gas exchange related to altered blood gases

c.

Deficient knowledge related to need for cardiac catheterization

d.

Need for high protein diet related to alteration in nutrition

ANS: c

c. This nursing diagnosis is written correctly. It defines a problem and its possible cause; in this case, the problem is the clients response to a diagnostic test.

a. A medical diagnosis should not be recorded as an etiology because nursing interventions cannot change the medical diagnosis. It would be appropriate to state Acute pain related to impaired skin integrity secondary to mastectomy incision.

b. This nursing diagnosis is written incorrectly because it uses supportive data of the problem as an etiology.

d. This nursing diagnosis does not identify the problem and etiology. It identifies the clients goal rather than the problem. It could be reworded as Imbalanced nutrition: less than body requirements related to inadequate protein intake.

REF: Text Reference: p. 307, Text Reference: p. 312

4. Nursing diagnoses meet specific criteria so they accurately reflect both the clients problem and the possible etiology involved. Of the following statements, which one is an example of an appropriately written nursing diagnosis?

a.

Cardiac output decreased related to motor vehicle accident

b.

Potential for injury related to improper teaching in the use of crutches

c.

Ineffective airway clearance related to increased secretions

d.

Risk for change in body image related to cancer

ANS: c

c. This nursing diagnosis is written appropriately. It identifies a problem by using a NANDA International diagnostic statement and connects it to its etiology.

a. This nursing diagnosis is written incorrectly. The etiology is not treatable.

b. This nursing diagnosis is written incorrectly. It identifies the nurses problem and not the clients.

d. This nursing diagnosis is written incorrectly. It uses a medical diagnosis for the etiology.

REF: Text Reference: p. 311

5. The nurse has diagnosed the clients problem as altered elimination. From the data base the nurse identifies all the following as appropriate etiologies for this diagnosis except:

a.

Poor fiber intake

b.

Limited fluid intake

c.

Total hip replacement

d.

Lower abdominal discomfort

ANS: c

c. Because the medical diagnosis requires medical interventions, it is legally inadvisable to use it in the nursing diagnosis. Rather, the nurse should identify the clients response, such as decreased mobility. The nurse should be able to provide nursing interventions that will treat the etiology.

a. Poor fiber intake would be an appropriate etiology for the problem of altered elimination.

b. Limited fluid intake would be an appropriate etiology for the nursing diagnosis of altered elimination.

d. Lower abdominal discomfort is an appropriate etiology for the nursing diagnosis for altered elimination.

REF: Text Reference: p. 311

6. The nurse is concerned that atelectasis may develop as a postoperative complication. Which of the following is an appropriate diagnostic label for this problem should it occur?

a.

Ineffective airway clearance

b.

Impaired gas exchange

c.

Decreased cardiac output

d.

Impaired spontaneous ventilation

ANS: b

b. A potential etiology for impaired gas exchange may be atelectasis.

a. Atelectasis would not be an etiology for ineffective airway clearance. Increased tenacious sputum production would be a possible etiology for ineffective airway clearance.

c. Atelectasis would not support the diagnostic label for decreased cardiac output.

d. Impaired spontaneous ventilation would not be an appropriate diagnostic label for atelectasis.

REF: Text Reference: p. 304, Text Reference: p. 305

7. The nurse recognizes that which one of the following statements is true with regard to the formulation of nursing diagnoses?

a.

The etiology of the diagnosis must be within the scope of the health care teams practice.

b.

The diagnosis must remain constant during the clients hospitalization.

c.

The diagnosis should include the problem and the related contributing conditions.

d.

The diagnosis should identify a cause and effect relation.

ANS: c

c. This is a true statement. Related factors are causative or other contributing factors that have influence the clients actual or potential response to the health problem and can be changed by nursing interventions.

a. The etiology or cause of the nursing diagnosis must be within the domain of nursing practice and a condition that responds to nursing interventions, not those of the entire health care team.

b. The nursing diagnosis does not have to remain constant during the clients hospitalization. It should change according to changes in the patient.

d. The nursing diagnosis does not identify a cause and effect relation; rather it indicates that the etiology contributes to or is associated with the clients problem.

REF: Text Reference: p. 307

8. When completing a client assessment and determining nursing diagnoses, the nurse may make an error. A diagnostic error can influence the application of the nursing care plan. A likely source for a nursing diagnosis error is if the nurse:

a.

Validates the assessment information in the data base

b.

Uses the North American Nursing Diagnosis Association (NANDA) list of diagnoses as a source

c.

Formulates a diagnosis too closely resembling a medical diagnosis

d.

Distinguishes the nursing focus instead of other health care disciplines

ANS: c

c. A nursing diagnosis should identify the clients response, not the medical diagnosis. Because the medical diagnosis requires medical interventions, it is legally inadvisable to include it in the nursing diagnosis.

a. A nurse should validate assessment data for accuracy and understanding.

b. Using the NANDA list of diagnoses as a source helps to ensure accuracy.

d. One purpose of the nursing diagnosis is to distinguish the nurses role from that of the physician. Another purpose is to help nurses focus on the role of nursing in client care. Nursing diagnoses promote understanding between nurses regarding clients health problems.

REF: Text Reference: p. 311

9. Identify the defining characteristics in the following nursing diagnosis: Altered speech related to recent neurological disturbance, as evidenced by inability to speak in complete sentences:

a.

Altered speech

b.

As evidenced by

c.

Recent neurological disturbances

d.

Inability to speak in complete sentences

ANS: d

d. Defining characteristics are assessment findings that support the nursing diagnosis. In this example, the inability to speak in complete sentences supports the nursing diagnosis of altered speech.

a. Altered speech is the diagnostic label identifying the problem.

b. As evidenced by is a connecting statement for the problem and the defining characteristics.

c. Recent neurologic disturbances is the etiology.

REF: Text Reference: p. 304

10. The nurse recognizes that the primary purpose of a nursing diagnosis is to:

a.

Support the medical plan of care

b.

Provide a standardized approach for all clients

c.

Recognize the clients response to an illness or situation

d.

Offer the nurses subjective view of the clients behaviors

ANS: c

c. The primary purpose of a nursing diagnosis is to recognize the clients response to an illness or situation. The nurse can then use the nursing diagnosis to select appropriate nursing interventions to achieve positive client outcomes.

a. A nursing diagnosis is based on the client, not on the medical plan of care.

b. Although nursing diagnoses may facilitate communication, it does not mean that they provide a standardized approach for all clients. Nursing diagnoses are individualized to meet the clients needs.

d. The primary purpose of nursing diagnoses is not to offer the nurses subjective view of the clients behaviors. Nursing diagnoses are based on subjective and objective client data and should not include the nurses personal beliefs and values.

REF: Text Reference: p. 300

11. Nursing diagnoses must meet specific criteria to reflect both the clients problem and the possible etiology involved. Which one of the following is an appropriate etiology for a nursing diagnosis?

a.

Abnormal blood gas levels

b.

Myocardial infarction

c.

Increased airway secretions

d.

Cardiac catheterization

ANS: c

c. Increased airway secretions is a condition that responds to nursing interventions and therefore would be an appropriate etiology for a nursing diagnosis.

a. Abnormal blood gas levels would not be an appropriate etiology for a nursing diagnosis because it is not a causative factor, but rather is a defining characteristic of a problem.

b. Myocardial infarction would not be an appropriate etiology for a nursing diagnosis because it is a medical diagnosis. Nursing interventions will not alter the medical diagnosis of myocardial infarction.

d. Cardiac catheterization is a diagnostic procedure and would not be an appropriate etiology for a nursing diagnosis. The clients response to the procedure would be the area of nursing concern.

REF: Text Reference: p. 307

12. Nursing diagnoses must meet specific criteria to reflect both the clients problem and the possible etiology involved. Which of the following is an appropriate etiology for a nursing diagnosis?

a.

Incisional pain

b.

Poor hygienic practices

c.

Needs bedpan frequently

d.

Inadequate prescription of medication by the physician

ANS: a

a. Incisional pain is an appropriate etiology for a nursing diagnosis. It is a condition that identifies the cause of a clients response to a health problem that a nurse can treat or manage.

b. Poor hygiene practices would not be an appropriate etiology for a nursing diagnosis because it insinuates a nurses prejudicial judgment.

c. Needs bedpan frequently is not an appropriate etiology because it identifies a nursing intervention, not an etiology.

d. Inadequate prescription of medication by the physician is not an appropriate etiology because it identifies the nurses problem, not the clients problem. The nursing diagnosis should center attention on client needs.

REF: Text Reference: p. 307

13. Nursing diagnoses must meet specific criteria to reflect accurately both the clients problem and the possible etiology involved. Of the following statements, which one is an example of an appropriately written nursing diagnosis?

a.

Diarrhea related to food intolerance

b.

Alteration in comfort related to pain

c.

Risk for impaired skin integrity related to poor hygiene habits

d.

Potential complications related to insufficient vascular access

ANS: a

a. This is a correctly written nursing diagnosis. It consists of a problem related to an etiology and is a condition that nursing interventions can treat or manage.

b. This nursing diagnosis is not written correctly because it is a circular statement. It would be appropriate to state Ineffective breathing pattern related to incisional pain.

c. This nursing diagnosis is not written correctly because it uses a nurses prejudicial judgment. It would be more appropriate and professional to state risk for impaired skin integrity related to knowledge about perineal care.

d. This nursing diagnosis is not written appropriately because it identifies a nursing problem, not a clients problem. It would be appropriate to state, Risk for infection related to presence of invasive lines.

REF: Text Reference: p. 307, Text Reference: p. 312

14. Nursing diagnoses must meet specific criteria to accurately reflect both the clients problem and the possible etiology involved. Of the following statements, which one is an example of an appropriately written nursing diagnosis?

a.

Chronic pain related to insufficient use of medication

b.

Pain related to difficulty ambulating

c.

Anxiety related to cardiac monitor

d.

Bedpan required frequently as a result of altered elimination pattern

ANS: a

a. This is an example of an appropriately written nursing diagnosis. It consists of a diagnostic label and the associated etiology. Nursing interventions can be directed at treating or managing the behavior of insufficient medication use.

b. This nursing diagnosis is not written correctly. What could be a defining characteristic is used as an etiology. This nursing diagnosis could be rewritten more appropriately as Impaired mobility related to pain as evidenced by difficulty ambulating, or it could be an inaccurate diagnostic label and could be rewritten as Anxiety related to difficulty in ambulating.

c. This nursing diagnosis is written incorrectly because it identifies the equipment rather than the clients response to the equipment. It would be appropriate to state deficient knowledge regarding the need for cardiac monitoring.

d. This nursing diagnosis is written incorrectly because it identifies a nursing intervention, not the clients problem. It could be reworded, Diarrhea related to food intolerance.

REF: Text Reference: p. 307, Text Reference: p. 312

15. The nurse is working with a client who has abnormal breath sounds, dyspnea, an intermittent cough, and variable respiratory rate. Based on this information, the nurse identifies the most appropriate nursing diagnosis as:

a.

Risk for injury

b.

Excess fluid volume

c.

Ineffective airway clearance

d.

Impaired spontaneous ventilation

ANS: c

c. The defining characteristics of abnormal breath sounds, dyspnea, an intermittent cough, and variable respiratory rate cue the nurse to the nursing diagnosis of ineffective airway clearance.

a. The nursing assessment data do not support the diagnostic label of risk for injury.

b. The nursing assessment data do not support the diagnostic label of excess fluid volume. Other defining characteristics would be noted such as edema, weight gain, and an elevated blood pressure.

d. The nursing assessment data do not most accurately describe impaired spontaneous ventilation. Other characteristics, such as apnea, would better support the diagnostic label of impaired spontaneous ventilation.

REF: Text Reference: p. 311

16. In selecting a nursing diagnosis, the nurse elects to use the recommended labels from NANDA. Which one of the following is a NANDA nursing diagnosis label?

a.

Risk for impaired parenting

b.

Abnormal hygienic care practices

c.

Coughing and dyspnea

d.

Frequent urination

ANS: a

a. Risk for impaired parenting is a NANDA nursing diagnosis label.

b. Abnormal hygienic care practices is not a NANDA nursing diagnosis label. It incorrectly implies a nurses prejudicial judgment.

c. Coughing and dyspnea are symptoms, not a NANDA nursing diagnosis label.

d. Frequent urination is a symptom, not a NANDA nursing diagnosis label.

REF: Text Reference: p. 304

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