Nursing_Diagnosis Questions With Answers.

Nursing_Diagnosis Questions With Answers. 1. After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse’s actions? a. To form a language that can be encoded only by nurses b. To distinguish the nurse’s role from the physician’s role c. To develop clinical judgment based on other’s intuition d. To help nurses focus on the scope of medical practice ANS: B The standard formal nursing diagnosis serves several purposes. Nursing diagnoses distinguish the nurse’s role from that of the physician/health care provider and help nurses focus on the scope of nursing practice (not medical) while fostering the development of nursing knowledge. A nursing diagnosis provides the precise deᴀ 밄 nition that gives all members of the health care team a common language for understanding the patient’s needs. A diagnosis is a clinical judgment based on information. DIF:Understand (comprehension)REF:225 | 227 OBJ: Discuss how a nursing diagnosis guides nursing practice. TOP: Diagnosis 10/15/2016 2/15 MSC:Management of Care 2. Which diagnosis will the nurse document in a patient’s care plan that is NANDA-I approved? a. Sore throat b. Acute pain c. Sleep apnea d. Heart failure ANS: B Acute pain is the only NANDA-I approved diagnosis listed. Sleep apnea and heart failure are medical diagnoses, and sore throat is subjective data. DIF:Understand (comprehension)REF:227 | 233 OBJ: Discuss how a nursing diagnosis guides nursing practice. TOP: Diagnosis MSC:Management of Care 3. A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe inᴀ 밄 ltrates. Which nursing diagnosis did the nurse write? a. Ineᴀ 洅 ective breathing pattern related to pneumonia b. Risk for infection related to chest x-ray procedure c. Risk for deᴀ 밄 cient ᴀ 밄 uid volume related to dehydration d. Impaired gas exchange related to alveolar-capillary membrane changes ANS: D 10/15/2016 3/15 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 factor should be the cause of the problem (nursing diagnosis) that a nurse can address. The related to factors of dehydration and pneumonia are all medical diagnoses that the nurse cannot change. A diagnostic test or a chronic dysfunction is not an etiology or a condition that a nursing intervention is able to treat. DIF:Apply (application)REF:230 | 232 | 236 OBJ: Discuss the relationship of critical thinking to the nursing diagnostic process. 4. The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate. Which part of the diagnostic statement does the nurse need to revise? a. Etiology b. Nursing diagnosis c. Collaborative problem d. Deᴀ 밄 ning characteristic ANS: A 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. A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient’s health status; there is no collaborative problem listed. The deᴀ 밄 ning characteristic (subjective and objective data that support the diagnosis) is appropriate for Impaired physical mobility. DIF:Apply (application)REF:233 | 235 | 236 OBJ: Diᴀ 洅 erentiate among a nursing diagnosis, medical diagnosis, and collaborative problem. 10/15/2016 4/15 5. A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing? a. Assigning clinical cues b. Deᴀ 밄 ning characteristics c. Diagnostic reasoning d. Diagnostic labeling ANS: C Diagnostic reasoning is deᴀ 밄 ned as a process of using the assessment data gathered about a patient to logically explain a clinical judgment, in this case a nursing diagnosis. Deᴀ 밄 ning characteristics are assessment ᴀ 밄 ndings that support the nursing diagnosis. Deᴀ 밄 ning characteristics are the subjective and objective clinical cues, which a nurse gathers intentionally and unintentionally. The nurse organizes all of the patient’s data into meaningful and usable data clusters, which lead to a diagnostic conclusion. Diagnostic labeling is simply the name of the diagnosis. DIF:Understand (comprehension)REF:230 OBJ: Discuss the relationship of critical thinking to the nursing diagnostic process.