CHAPTER 17: ANALYSIS AND NURSING DIAGNOSIS {Potter: Fundamentals of Nursing, 11th Edition}

C HAPTER 17: A NALYSIS AND N URSING
D IAGNOSIS
Potter: Fundamentals of Nursing, 11th Edition



MULTIPLE CHOICE


1. The patient database reveals that a patient has decreased oral intake,
decreased ox ygen saturation when ambulating, reports of shortness of
breath when getting out of bed, and a productive cough. Which elements
will the nurse identify as defining characteristics for the diagnostic label
of Activit y intolerance?
a. Decreased oral intake an d decreased oxygen saturation when
ambulating
b. Decreased ox ygen saturation when ambulating and reports of
shortness of breath when getting out of bed
c. Reports of shortness of breath when getting out of bed and a
productive cough
d. Productive cough and decrease d oral intake



ANS: B



There are defining characteristics (observable assessment cues such as
patient behavior, physical signs) that support each problem -focused
diagnostic judgment. The signs and symptoms, or defining
characteristics, for the diagnosis Ac tivity intolerance include decreased
oxygen saturation when ambulating and reports of shortness of breath
when getting out of bed. The key to supporting the diagnosis of
Activit y intolerance is that onl y these two characteristics involve how

, the patient tolerates activit y. Decreased oral intake and productive
cough do not define activit y intolerance.



DIF: Anal yze (anal ysis) OBJ: Appl y critical thinking in the
diagnostic reasoning process. TOP: Diagnosis MSC:
Management of Care



2. A nurse performs an asses sment on a patient. Which assessment data will
the nurse use as an etiology for Acute pain?
a. Discomfort while changing position
b. Reports pain as a 7 on a 0 to 10 scale
c. Disruption of tissue integrit y
d. Dull headache



ANS: C



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



DIF: Appl y (applicat ion) OBJ: Appl y critical thinking in
the diagnostic reasoning process. TOP: Diagnosis MSC:
Management of Care



3. A new nurse writes the following nursing diagnoses on a patient’s care
plan. Which nursing diagnosis will cause the nurse manager to intervene ?
a. Wandering
b. Hemorrhage

, c. Urinary retention
d. Impaired swallowing



ANS: B



Hemorrhage is a collaborative problem, not a nursing diagnosis; the
nurse manager will need to correct this misunderstanding with the new
nurse. Nurses manage collaborative problems such as hemorrhage,
infection, and paral ysis using medical, nursing, and allied health (e.g.,
physical therapy) interventions. Wandering, urinary retention, and
impaired swallowing are all examples of nursing diagnoses.



DIF: Anal yze (anal ysis) OBJ: Identify sources of nursing
diagnostic errors. TOP: Diagnosis MSC: Management of Care



4. A patient has a bacterial infection in left lower leg. Which nursing
diagnosis will the nurse add to the patient’s care plan?
a. Infection
b. Risk for infection
c. Impaired skin integrit y
d. Staphylococcal leg infection



ANS: C



Impaired skin integrity is the onl y nursing diagnosis listed that will
correlate to the patient information. While risk for infection is a
nursing diagnosis, the patient is not at risk; the patient has an actual
infection. Infection can be a medical diagnosis as well as a
collaborative problem. Staphylococcal leg infection is a medical
diagnosis.