Chapter 17: Nursing Diagnosis Nursing School Test Banks

Test Bank

MULTIPLE CHOICE

1. One purpose of using standard formal nursing diagnoses in practice is to

a.

Form a language that can be encoded only by nurses.

b.

Distinguish the nurses role from the physicians role.

c.

Allow for the communication of patient needs to assistive personnel.

d.

Help nurses focus on the scope of medical practice.

ANS: B

The standard formal nursing diagnosis serves several purposes. A nursing diagnosis provides the precise definition that gives all members of the health care team a common language for understanding the patients needs. Nursing diagnoses allow nurses to communicate what they do among themselves, with other health care professionals, and the public. Nursing diagnoses distinguish the nurses role from that of the physician, and help nurses focus on the scope of nursing practice while fostering the development of nursing knowledge.

DIF: Remember REF: 224

OBJ: Discuss the purposes of using nursing diagnosis in practice.

TOP: Diagnosis MSC: Safe and Effective Care Environment

2. Which diagnosis below is NANDA-I approved?

a.

Sleep disorder

b.

Acute pain

c.

Sore throat

d.

High blood pressure

ANS: B

Acute pain is the only NANDA-Iapproved diagnosis listed. Sleep disorder and high blood pressure (hypertension) are medical diagnoses, and sore throat is a subjective complaint.

DIF: Understand REF: 225

OBJ: Discuss the purposes of using nursing diagnosis in practice.

TOP: Diagnosis MSC: Safe and Effective Care Environment

3. Which nursing diagnostic statement is accurately written for a patient with a medical diagnosis of pneumonia?

a.

Risk for infection related to lower lobe infiltrate

b.

Risk for deficient fluid volume related to dehydration

c.

Impaired gas exchange related to alveolar-capillary membrane changes

d.

Ineffective breathing pattern related to pneumonia

ANS: C

The related to factor of alveolar-capillary membrane changes is accurately written because it is a patient response to the disease process of pneumonia that the nurse can treat. The related to factors lower lobe infiltrate, dehydration, and pneumonia are all medical diagnoses that the nurse cannot change. Lower lobe infiltrate is simply another term for pneumonia, a medical diagnosis. The related to factor should be the cause of the problem (nursing diagnosis) that a nurse can address.

DIF: Understand REF: 225| 227| 229

OBJ: Discuss the relationship of critical thinking to the nursing diagnostic process.

TOP: Diagnosis MSC: Safe and Effective Care Environment

4. The charge nurse is reviewing a patients plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patients inability to ambulate to bathroom. The nurse needs to revise which part of the diagnostic statement?

a.

Nursing diagnosis

b.

Etiology

c.

Patient chief complaint

d.

Defining characteristic

ANS: B

The etiology, or related to factor, of tibial fracture is a medical diagnosis and needs to be revised. The nursing diagnosis is appropriate because the patient is unable to ambulate. The patients chief complaint is what the patient subjectively states is the problem. No subjective data are included in the diagnostic statement. The defining characteristic (subjective and objective data that support the diagnosis) is appropriate for Impaired physical mobility.

DIF: Apply REF: 225-227

OBJ: Differentiate among nursing diagnosis, medical diagnosis, and collaborative problem.

TOP: Diagnosis MSC: Safe and Effective Care Environment

5. The process of using assessment data gathered about a patient combined with critical thinking to explain a nursing diagnosis is known as

a.

Diagnostic reasoning.

b.

Defining characteristics.

c.

Assigning clinical criteria.

d.

Diagnostic labeling.

ANS: A

Diagnostic reasoning is defined as a process of using the assessment data gathered about a patient to logically explain a clinical judgment, in this case a nursing diagnosis. Defining characteristics are assessment findings that support the nursing diagnosis. Clinical criteria are objective signs or subjective symptoms. Diagnostic labeling is simply assigning the diagnosis.

DIF: Remember REF: 224| 228

OBJ: Discuss the relationship of critical thinking to the nursing diagnostic process.

TOP: Diagnosis MSC: Safe and Effective Care Environment

6. A patient presents to the emergency department following a motor vehicle crash and suffers from a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and complains only of moderate discomfort. What is the most pertinent nursing diagnosis to be included in the plan of care based on the assessment data provided?

a.

Posttrauma syndrome

b.

Constipation

c.

Urinary retention

d.

Acute pain

ANS: D

Based on the assessment data provided, the only supportive evidence for one of the diagnosis options is Complains of moderate discomfort, which would support Acute pain. No supportive evidence is provided for any of the other diagnoses. The patient may indeed develop signs or symptoms of the other problems, but supportive data are presently lacking in the provided information.

DIF: Apply REF: 225| 227

OBJ: Discuss the relationship of critical thinking to the nursing diagnostic process.

TOP: Diagnosis MSC: Safe and Effective Care Environment

7. The nurse is reviewing a patients database for significant changes and discovers that the patient has not voided in over 8 hours. The patients kidney function labs are abnormal, and the patients oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?

a.

Diagnosis

b.

Planning

c.

Implementation

d.

Evaluation

ANS: A

After a thorough assessment, the nurse should proceed to analyzing the data and formulating a nursing diagnosis before proceeding with developing the plan of care and determining appropriate interventions. The evaluation phase involves determining whether the interventions were effective.

DIF: Understand REF: 222

OBJ: Describe the steps of the nursing diagnostic process. TOP: Diagnosis

MSC: Safe and Effective Care Environment

8. A patient with a spinal cord injury is seeking to enhance his urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nursing diagnosis Readiness for enhanced urinary elimination is which type of diagnosis?

a.

Actual

b.

Risk

c.

Health promotion

d.

Wellness

ANS: D

The patients desire is to increase his specific level of wellness to a higher level of wellness. An actual diagnosis describes human responses to health conditions or life processes that exist. A risk diagnosis describes human responses to health conditions/life processes that will possibly develop. A health promotion diagnosis is a clinical judgment of a patients motivation and desire to enhance well-being and does not require a current level of wellness.

DIF: Apply REF: 227-228

OBJ: Describe the steps of the nursing diagnostic process. TOP: Diagnosis

MSC: Safe and Effective Care Environment

9. A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistant then reports to the nurse that the patients blood pressure was low when it was taken at 0830. The nursing assistant states she was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is re-checked and it has dropped even lower. The nurse first made an error in what phase of the nursing process?

a.

Assessment

b.

Diagnosis

c.

Planning

d.

Evaluation

ANS: A

The diagnostic process should flow from the assessment. Without a thorough assessment, the nurse is more apt to misdiagnose a patients responses, and the wrong interventions may be implemented. In this case, the nurse should have assessed the patients blood pressure before giving the medication. The nurse could have prevented the patients untoward reaction if the low blood pressure was assessed first. The nurse could have notified the physician, held the medication, or taken other steps to prevent an adverse reaction.

DIF: Apply REF: 222| 231-232

OBJ: Describe the steps of the nursing diagnostic process. TOP: Diagnosis

MSC: Safe and Effective Care Environment

10. Identify the defining characteristics in the nursing diagnosis statement: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and complaints of abdominal pain.

a.

Decreased gastrointestinal motility

b.

Pain medication

c.

Abdominal distention

d.

Constipation

ANS: C

Abdominal distention, no reported bowel movement, and abdominal pain are the defining characteristics. Decreased gastrointestinal motility secondary to pain medication is an etiology or related to factor. Constipation is the identified problem derived from the defining characteristics.

DIF: Understand REF: 225-227

OBJ: Explain how defining characteristics and the etiological process individualize a nursing diagnosis. TOP: Diagnosis MSC: Safe and Effective Care Environment

11. The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, complaints of shortness of breath when getting out of bed, and a productive cough. What are the defining characteristics for the diagnostic label of Activity intolerance?

a.

Decreased oral intake and decreased oxygen saturation when ambulating

b.

Decreased oxygen saturation when ambulating and complaints of shortness of breath when getting out of bed

c.

Complaints of shortness of breath when getting out of bed and a productive cough

d.

Productive cough and decreased oral intake

ANS: B

The signs and symptoms, or defining characteristics, for the diagnosis Activity intolerance include decreased oxygen saturation when ambulating and complaints of shortness of breath when getting out of bed. The key to supporting the diagnosis of Activity intolerance is that only these two characteristics involve how the patient tolerates activity.

DIF: Apply REF: 226

OBJ: Explain how defining characteristics and the etiological process individualize a nursing diagnosis. TOP: Diagnosis MSC: Safe and Effective Care Environment

12. Which of these selections is an etiology for Acute pain versus a defining characteristic?

a.

Complaint of pain as a 7 on a 0 to 10 scale

b.

Disruption of tissue integrity

c.

Dull headache

d.

Discomfort while changing position

ANS: B

Disruption of tissue integrity is a possible cause or etiology of pain. A complaint of pain, headache, and discomfort are examples of things a patient might say (subjective data or defining characteristics) that lead a nurse to select Acute pain as a nursing diagnosis.

DIF: Apply REF: 229

OBJ: Explain how defining characteristics and the etiological process individualize a nursing diagnosis. TOP: Diagnosis MSC: Safe and Effective Care Environment

13. A patient of Middle Eastern descent has lost 5 lbs during hospitalization and states that the food offered is not allowed in his diet owing to religious preferences. Based on this information, an appropriate nursing diagnostic statement is Imbalanced nutrition: less than body requirements related to

a.

Religious preferences.

b.

Decreased oral intake.

c.

Weight loss.

d.

Race and ethnicity.

ANS: B

The cause or related to factor in this case is the patients lack of oral intake due to lack of appropriate food choices. The patients religious preferences, race, and ethnicity did not cause his weight loss. Ultimately, the lack of food choices and his decreased intake caused him to lose weight. Weight loss is a sign of imbalanced nutrition, not a cause. The weight loss would be noticed during the assessment and would lead to the nursing diagnosis, not in reverse order.

DIF: Analyze REF: 229-230

OBJ: Explain how defining characteristics and the etiological process individualize a nursing diagnosis. TOP: Diagnosis MSC: Safe and Effective Care Environment

14. After completing a thorough assessment to formulate a patient database, the nurse should proceed to which step of the nursing process?

a.

Diagnosis

b.

Planning

c.

Implementation

d.

Evaluation

ANS: A

Following assessment, analyzing the data and assigning a nursing diagnosis is the next step in the nursing process. Planning occurs after assigning the problem to establish goals. Nursing interventions are carried out in the implementation phase. The evaluation phase occurs after intervening to establish whether interventions have been effective in helping the patient meet his/her goals.

DIF: Remember REF: 231-233 OBJ: Describe sources of diagnostic errors.

TOP: Diagnosis MSC: Safe and Effective Care Environment

15. A new graduate nurse is not sure what the heart sound is that she is listening to on a patient. To avoid diagnostic error, what should the nurse do?

a.

Assign the nursing diagnosis of Decreased cardiac output.

b.

Ask the patient if he has a history of cardiac problems before assigning the diagnosis ofDecisional conflict.

c.

Check the previous shifts assessment and document what was noted on the last shift.

d.

Ask a more experienced nurse to listen also.

ANS: D

The potential diagnostic error here is an error in data collection. If a new nurse is not comfortable with his/her assessment technique, he or she should ask another nurse to validate the findings. Diagnosing before validating assessment findings leads to the potential for error. Assessment data are not sufficient to assign the diagnoses Decreased cardiac output and Decisional conflict. Every nurse needs to perform his or her own assessment. A patients status can change very rapidly. A nurse who copies the previous shifts assessment is not practicing according to standards of practice and is violating the code of ethics.

DIF: Apply REF: 231-233 OBJ: Describe sources of diagnostic errors.

TOP: Diagnosis MSC: Safe and Effective Care Environment

16. Which of these findings, when evaluating another nurse developing a plan of care, should the charge nurse recognize as a source of diagnostic error?

a.

Assigning diagnoses while completing the database

b.

Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous antibiotics

c.

Completing the interview before performing the physical examination

d.

Documenting cultural and religious preferences

ANS: A

Diagnosis should take place only after the database is completed. The data should be clustered and reviewed to see if any patterns are present before a nursing diagnosis is assigned. Risk for infection is an appropriate diagnosis for a patient with an intravenous (IV) site in place. The IV site involves a break in skin integrity and is a potential source of infection. The diagnostic process should proceed in steps. Completing the interview before the physical examination is appropriate. The patients cultural background and developmental stage are important to include in a patient database.

DIF: Analyze REF: 231-233 OBJ: Describe sources of diagnostic errors.

TOP: Diagnosis MSC: Safe and Effective Care Environment

17. A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. After analyzing these data, the nurse assigns which of the following nursing diagnoses?

a.

Adult failure to thrive

b.

Hypothermia

c.

Deficient fluid volume

d.

Nausea

ANS: C

The signs the patient is exhibiting are consistent with dehydration. Even without knowing the clinical manifestations of dehydration, the question can be answered by the process of elimination. Adult failure to thrive, hypothermia, and nausea are not appropriate diagnoses because data are insufficient to support these diagnoses.

DIF: Analyze REF: 225-226

OBJ: Identify nursing diagnoses from a nursing assessment. TOP: Diagnosis

MSC: Safe and Effective Care Environment

18. Which of these questions would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea?

a.

What types of foods do you think caused your upset stomach?

b.

How many bowel movements a day have you had?

c.

Are you able to get to the bathroom in time?

d.

What medications are you currently taking?

ANS: B

The nurse needs to first ensure that the symptoms support the diagnosis. By definition, diarrhea means that a patient is having frequent stools. Asking about irritating foods and medications may help the nurse determine the cause of the diarrhea, but first the nurse needs to make sure the diagnosis is appropriate. Asking the patient if he can make it to the bathroom will help to establish a diagnosis of incontinence, not diarrhea. The question is asking for the most appropriate statement to establish the diagnosis of Diarrhea.

DIF: Apply REF: 225-226

OBJ: Identify nursing diagnoses from a nursing assessment. TOP: Diagnosis

MSC: Safe and Effective Care Environment

19. A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention?

a.

Do you feel like you need to use the bathroom?

b.

Are you able to walk to the bathroom by yourself?

c.

When was the last time you took your medicine?

d.

Do you have a safety rail in your bathroom at home?

ANS: A

The nurse must establish that the patient feels the urge and is unable to void. The question Do you feel like you need to use the bathroom? is the most appropriate to ask. This question can be answered without knowledge of the diagnosis of Urinary retention. Discussing the ability to walk to the bathroom and asking about safety rails pertain to mobility and safety issues, not to retention of urine. Taking certain medications may lead to urinary retention, but that information would establish the etiology. The question is asking for the nurse to first establish the correct diagnosis.

DIF: Apply REF: 225-226

OBJ: Identify nursing diagnoses from a nursing assessment. TOP: Diagnosis

MSC: Safe and Effective Care Environment

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