NUR 316 Exam 1 || Acknowledged Answers 100%.
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 correct answers B
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 correct answers B
A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of
pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the
nurse write?
A) Ineffective breathing pattern related to pneumonia
B) Risk for infection related to chest x-ray procedure
C) Risk for deficient fluid volume related to dehydration
D) Impaired gas exchange related to alveolar-capillary membrane changes correct answers D
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) Defining characteristic correct answers A
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) Defining characteristics
C) Diagnostic reasoning
D) Diagnostic labeling correct answers C
A patient presents to the emergency department following a motor vehicle crash and suffers 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 reports only moderate discomfort. Which is the most
pertinent nursing diagnosis the nurse will include in the plan of care?
A) Posttrauma syndrome
B) Constipation
C) Acute pain
D) Anxiety correct answers C
The nurse is reviewing a patient's database for significant changes and discovers that the patient
has not voided in over 8 hours. The patient's kidney function lab results are abnormal, and the
patient's 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 correct answers A
A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning
self-catheterization versus assisted catheterization by home health nurses and family members.
,The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of
diagnosis did the nurse write?
A) Risk
B) Problem focused
C) Health promotion
D) Collaborative problem correct answers C
A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900.
The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure
was low when it was taken at 0830. The NAP states that 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 rechecked and it has dropped even lower. In which phase of the nursing process did
the nurse first make an error?
A) Assessment
B) Diagnosis
C) Implementation
D) Evaluation correct answers A
A nurse adds the following diagnosis to a patient's care plan: 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 abdominal pain. Which
element did the nurse write as the defining characteristic?
A) Decreased gastrointestinal motility
B) Pain medication
C) Abdominal distention
D) Constipation correct answers C
The patient database reveals that a patient has decreased oral intake, decreased oxygen 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
Activity intolerance?
, A) Decreased oral intake and decreased oxygen saturation when ambulating
B) Decreased oxygen 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 decreased oral intake correct answers B
A nurse performs an assessment 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 integrity
D) Dull headache correct answers C
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 correct answers B
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 integrity
D) Staphylococcal leg infection correct answers C
A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse
document?
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 correct answers B
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 correct answers B
A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of
pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the
nurse write?
A) Ineffective breathing pattern related to pneumonia
B) Risk for infection related to chest x-ray procedure
C) Risk for deficient fluid volume related to dehydration
D) Impaired gas exchange related to alveolar-capillary membrane changes correct answers D
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) Defining characteristic correct answers A
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) Defining characteristics
C) Diagnostic reasoning
D) Diagnostic labeling correct answers C
A patient presents to the emergency department following a motor vehicle crash and suffers 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 reports only moderate discomfort. Which is the most
pertinent nursing diagnosis the nurse will include in the plan of care?
A) Posttrauma syndrome
B) Constipation
C) Acute pain
D) Anxiety correct answers C
The nurse is reviewing a patient's database for significant changes and discovers that the patient
has not voided in over 8 hours. The patient's kidney function lab results are abnormal, and the
patient's 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 correct answers A
A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning
self-catheterization versus assisted catheterization by home health nurses and family members.
,The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of
diagnosis did the nurse write?
A) Risk
B) Problem focused
C) Health promotion
D) Collaborative problem correct answers C
A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900.
The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure
was low when it was taken at 0830. The NAP states that 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 rechecked and it has dropped even lower. In which phase of the nursing process did
the nurse first make an error?
A) Assessment
B) Diagnosis
C) Implementation
D) Evaluation correct answers A
A nurse adds the following diagnosis to a patient's care plan: 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 abdominal pain. Which
element did the nurse write as the defining characteristic?
A) Decreased gastrointestinal motility
B) Pain medication
C) Abdominal distention
D) Constipation correct answers C
The patient database reveals that a patient has decreased oral intake, decreased oxygen 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
Activity intolerance?
, A) Decreased oral intake and decreased oxygen saturation when ambulating
B) Decreased oxygen 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 decreased oral intake correct answers B
A nurse performs an assessment 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 integrity
D) Dull headache correct answers C
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 correct answers B
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 integrity
D) Staphylococcal leg infection correct answers C
A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse
document?
