CHAPTER 17 NURSING DIAGNOSIS PRACTICE
QUESTIONS WITH RATIONALES 2026/2027
PASS GUIDE EXAMS
1.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?
A. Disturbed Sleep Pattern evidenced by frequent awakening
B. Disturbed Sleep Pattern related to family caregiving responsibilities
C. Disturbed Sleep Pattern related to need to improve sleep habits
D. Disturbed Sleep Pattern related to caregiving responsibilities as evidenced by
frequent awakening and not feeling rested - ANS ✅✅-D
A nursing diagnosis in a PES format includes the diagnostic label, related factor, and
the defining characteristics by which the diagnosis is evidenced. The second nursing
diagnosis is the correct format in the two-part format for writing a diagnosis. The first
diagnosis has no related factor. The third diagnosis is an error, using a goal as a related
factor.
2. 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?
A. Infant crying at breast
, B. Infant unable to latch on to breast correctly
C. Mother's deficient knowledge
D. Lack of infant weight gain - ANS ✅✅-C
In this scenario the related factor is the mother's deficient knowledge. A related factor
is a condition, historical factor, or etiology that gives a context for the defining
characteristics, in this case the infant crying, inability to latch on to breast, and absent
weight gain.
3. 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:
A. Collaborative data set.
B. Diagnostic label.
C. Related factors.
D. Data cluster. - ANS ✅✅-D.
A data cluster is a set of cues (i.e., the signs or symptoms gathered during
assessment).
4. 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. What are the 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
A. 2, 3, 4, 1
B. 3, 2, 4, 1
QUESTIONS WITH RATIONALES 2026/2027
PASS GUIDE EXAMS
1.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?
A. Disturbed Sleep Pattern evidenced by frequent awakening
B. Disturbed Sleep Pattern related to family caregiving responsibilities
C. Disturbed Sleep Pattern related to need to improve sleep habits
D. Disturbed Sleep Pattern related to caregiving responsibilities as evidenced by
frequent awakening and not feeling rested - ANS ✅✅-D
A nursing diagnosis in a PES format includes the diagnostic label, related factor, and
the defining characteristics by which the diagnosis is evidenced. The second nursing
diagnosis is the correct format in the two-part format for writing a diagnosis. The first
diagnosis has no related factor. The third diagnosis is an error, using a goal as a related
factor.
2. 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?
A. Infant crying at breast
, B. Infant unable to latch on to breast correctly
C. Mother's deficient knowledge
D. Lack of infant weight gain - ANS ✅✅-C
In this scenario the related factor is the mother's deficient knowledge. A related factor
is a condition, historical factor, or etiology that gives a context for the defining
characteristics, in this case the infant crying, inability to latch on to breast, and absent
weight gain.
3. 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:
A. Collaborative data set.
B. Diagnostic label.
C. Related factors.
D. Data cluster. - ANS ✅✅-D.
A data cluster is a set of cues (i.e., the signs or symptoms gathered during
assessment).
4. 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. What are the 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
A. 2, 3, 4, 1
B. 3, 2, 4, 1
