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Chapter 17 Nursing Diagnosis Questions and
Correct Answers
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
definition 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.)
Which diagnosis will the nurse document in a patient's care plan
that is NANDA-I approved?
a.
Sore throat
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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.)
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 Ans: — D
(The related to factor of alveolar-capillary membrane changes is
accurately written because it is a patient response to the disease
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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.)
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 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 defining characteristic (subjective and objective data that
support the diagnosis) is appropriate for Impaired physical
mobility.)
© 2025 All rights reserved
Chapter 17 Nursing Diagnosis Questions and
Correct Answers
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
definition 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.)
Which diagnosis will the nurse document in a patient's care plan
that is NANDA-I approved?
a.
Sore throat
© 2025 All rights reserved
, 2 | Page
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.)
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 Ans: — D
(The related to factor of alveolar-capillary membrane changes is
accurately written because it is a patient response to the disease
© 2025 All rights reserved
, 3 | Page
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.)
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 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 defining characteristic (subjective and objective data that
support the diagnosis) is appropriate for Impaired physical
mobility.)
© 2025 All rights reserved
