Practice T2
Which is an example of an actual nursing diagnosis?
1 Risk for acute confusion
2 Impaired social interaction
3 Readiness for enhanced nutrition
4 Readiness for increased family coping - CORRECT ANSWER-2 Impaired social interaction
Impaired social interaction is an example of an actual nursing diagnosis. Actual nursing diagnoses
are the responses of a person to a health condition. "Risk for" nursing diagnoses define human
responses to conditions that have not occurred yet. Risk for acute confusion is an example of this
kind of diagnosis. A health promotion nursing diagnosis is the clinical judgment of an individual's or
family's willingness to improve health. Readiness for enhanced nutrition and readiness for
enhanced family coping are examples of health promotion nursing diagnoses.
A nurse has made a nursing diagnosis without validating the data obtained from the client. Into
what category does this error fall?
1 Labeling
2 Collecting
3 Clustering
4 Interpreting - CORRECT ANSWER-1 Labeling
The nurse's error of failure to validate the data is categorized as labeling. Errors at the collecting
level include inaccurate data, missing data, and disorganization. Errors at the clustering level
include insufficient clusters of cues, premature or early closure, and incorrect clustering. At the
interpreting level, errors include failure to consider conflicting cues and failure to consider cultural
influences or developmental stage.
Which step of the nursing process is directly affected if the nurse does not make a nursing
diagnosis?
1 Planning
2 Evaluation
3 Assessment
4 Implementation - CORRECT ANSWER-1 Planning
The planning phase of the nursing process is directly affected if the nurse does not make a
nursing diagnosis. The nurse cannot plan or interpret correctly if the client's problems are not
clear. The evaluation phase of the nursing process is not directly affected by the nursing
diagnosis. A nursing diagnosis is based on an accurate assessment. The nurse must obtain and
document a comprehensive assessment. In the absence of nursing diagnosis, the nurse cannot
implement appropriate nursing interventions. The implementation phase is directly affected if there
is no plan of care.
Which client is likely to have a health promotion nursing diagnosis?
1 The client with acute pain due to appendicitis.
2 The client who is willing to take a 30-minute walk daily.
3 The elderly client with dementia admitted to the healthcare facility.
4 The client with reduced cognitive ability while recovering from surgery. - CORRECT ANSWER-2
The client who is willing to take a 30-minute walk daily.
, A health promotion nursing diagnosis is a clinical judgment of an individual's desire to increase
well-being. A client who is willing to take a 30-minute walk daily is expressing a desire to improve
health behavior. The nurse identifies a health promotion nursing diagnosis for this client. Acute
pain due to appendicitis is an actual nursing diagnosis. The nurse selects an actual nursing
diagnosis when there is sufficient assessment data to establish the nursing diagnosis. It describes
the client's response to a particular health condition. A risk nursing diagnosis describes an
individual's response to health conditions that may develop in a vulnerable individual. The elderly
client with dementia may have a risk nursing diagnosis for confusion. The client recovering from
surgery has reduced cognitive ability and may have a risk nursing diagnosis for confusion or falls
Which feature is characteristic of a risk nursing diagnosis?
1 The diagnosis does not have related factors.
2 The diagnosis can be used in any health state.
3 The defining characteristics support the diagnostic judgment.
4 The defining characteristics are supported by a client's readiness. - CORRECT ANSWER-1 The
diagnosis does not have related factors.
A risk nursing diagnosis describes human responses to health conditions that may develop in a
vulnerable individual, family, or community. Risk diagnoses do not have related factors or defining
characteristics because they have not occurred yet. A risk diagnosis has risk factors that help the
nurse plan preventive measures. A health promotion nursing diagnosis can be applied to any
individual with a desire to enhance health behaviors in any health state. An actual diagnosis is
formed when the defining characteristics support the diagnostic judgment. There must be sufficient
nursing assessment data to establish an actual diagnosis. A health promotion nursing diagnosis is
a clinical judgment of an individual's readiness to increase well-being.
Which related factor is appropriate for a nursing diagnosis?
1 Prostectomy
2 Trauma of incision
3 Acute renal failure
4 Knee replacement surgery - CORRECT ANSWER-2 Trauma of incision
The related factor or etiology of a nursing diagnosis is always within the nursing domain. The
nurse must ensure that the related factor is a condition that responds to nursing interventions.
Trauma of incision is an appropriate related factor for a nursing diagnosis. A prostectomy is a
medical condition that cannot be influenced by nursing actions. Similarly, acute renal failure is also
a medical condition. Nursing interventions should be directed towards behaviors or conditions that
can be managed or treated by the nurse. Knee replacement surgery is a medical condition that
cannot be managed by nursing interventions.
The nurse is aware that the nursing diagnosis should follow the North American Nursing Diagnosis
Association International (NANDA-I) label. How should the nurse document the nursing diagnosis
in a three-part format?
1 NANDA-I label, related factor, and etiologies
2 NANDA-I label, risk factor, and nursing interventions
3 NANDA-I label, related factor, and nursing interventions
4 NANDA-I label, related factor, and defining characteristics - CORRECT ANSWER-4 NANDA-I
label, related factor, and defining characteristics
The three-part nursing diagnosis label consists of the NANDA-I label, related factor, and defining
characteristics. This format is also known as the problem, etiology, and symptoms (PES) format.
Which is an example of an actual nursing diagnosis?
1 Risk for acute confusion
2 Impaired social interaction
3 Readiness for enhanced nutrition
4 Readiness for increased family coping - CORRECT ANSWER-2 Impaired social interaction
Impaired social interaction is an example of an actual nursing diagnosis. Actual nursing diagnoses
are the responses of a person to a health condition. "Risk for" nursing diagnoses define human
responses to conditions that have not occurred yet. Risk for acute confusion is an example of this
kind of diagnosis. A health promotion nursing diagnosis is the clinical judgment of an individual's or
family's willingness to improve health. Readiness for enhanced nutrition and readiness for
enhanced family coping are examples of health promotion nursing diagnoses.
A nurse has made a nursing diagnosis without validating the data obtained from the client. Into
what category does this error fall?
1 Labeling
2 Collecting
3 Clustering
4 Interpreting - CORRECT ANSWER-1 Labeling
The nurse's error of failure to validate the data is categorized as labeling. Errors at the collecting
level include inaccurate data, missing data, and disorganization. Errors at the clustering level
include insufficient clusters of cues, premature or early closure, and incorrect clustering. At the
interpreting level, errors include failure to consider conflicting cues and failure to consider cultural
influences or developmental stage.
Which step of the nursing process is directly affected if the nurse does not make a nursing
diagnosis?
1 Planning
2 Evaluation
3 Assessment
4 Implementation - CORRECT ANSWER-1 Planning
The planning phase of the nursing process is directly affected if the nurse does not make a
nursing diagnosis. The nurse cannot plan or interpret correctly if the client's problems are not
clear. The evaluation phase of the nursing process is not directly affected by the nursing
diagnosis. A nursing diagnosis is based on an accurate assessment. The nurse must obtain and
document a comprehensive assessment. In the absence of nursing diagnosis, the nurse cannot
implement appropriate nursing interventions. The implementation phase is directly affected if there
is no plan of care.
Which client is likely to have a health promotion nursing diagnosis?
1 The client with acute pain due to appendicitis.
2 The client who is willing to take a 30-minute walk daily.
3 The elderly client with dementia admitted to the healthcare facility.
4 The client with reduced cognitive ability while recovering from surgery. - CORRECT ANSWER-2
The client who is willing to take a 30-minute walk daily.
, A health promotion nursing diagnosis is a clinical judgment of an individual's desire to increase
well-being. A client who is willing to take a 30-minute walk daily is expressing a desire to improve
health behavior. The nurse identifies a health promotion nursing diagnosis for this client. Acute
pain due to appendicitis is an actual nursing diagnosis. The nurse selects an actual nursing
diagnosis when there is sufficient assessment data to establish the nursing diagnosis. It describes
the client's response to a particular health condition. A risk nursing diagnosis describes an
individual's response to health conditions that may develop in a vulnerable individual. The elderly
client with dementia may have a risk nursing diagnosis for confusion. The client recovering from
surgery has reduced cognitive ability and may have a risk nursing diagnosis for confusion or falls
Which feature is characteristic of a risk nursing diagnosis?
1 The diagnosis does not have related factors.
2 The diagnosis can be used in any health state.
3 The defining characteristics support the diagnostic judgment.
4 The defining characteristics are supported by a client's readiness. - CORRECT ANSWER-1 The
diagnosis does not have related factors.
A risk nursing diagnosis describes human responses to health conditions that may develop in a
vulnerable individual, family, or community. Risk diagnoses do not have related factors or defining
characteristics because they have not occurred yet. A risk diagnosis has risk factors that help the
nurse plan preventive measures. A health promotion nursing diagnosis can be applied to any
individual with a desire to enhance health behaviors in any health state. An actual diagnosis is
formed when the defining characteristics support the diagnostic judgment. There must be sufficient
nursing assessment data to establish an actual diagnosis. A health promotion nursing diagnosis is
a clinical judgment of an individual's readiness to increase well-being.
Which related factor is appropriate for a nursing diagnosis?
1 Prostectomy
2 Trauma of incision
3 Acute renal failure
4 Knee replacement surgery - CORRECT ANSWER-2 Trauma of incision
The related factor or etiology of a nursing diagnosis is always within the nursing domain. The
nurse must ensure that the related factor is a condition that responds to nursing interventions.
Trauma of incision is an appropriate related factor for a nursing diagnosis. A prostectomy is a
medical condition that cannot be influenced by nursing actions. Similarly, acute renal failure is also
a medical condition. Nursing interventions should be directed towards behaviors or conditions that
can be managed or treated by the nurse. Knee replacement surgery is a medical condition that
cannot be managed by nursing interventions.
The nurse is aware that the nursing diagnosis should follow the North American Nursing Diagnosis
Association International (NANDA-I) label. How should the nurse document the nursing diagnosis
in a three-part format?
1 NANDA-I label, related factor, and etiologies
2 NANDA-I label, risk factor, and nursing interventions
3 NANDA-I label, related factor, and nursing interventions
4 NANDA-I label, related factor, and defining characteristics - CORRECT ANSWER-4 NANDA-I
label, related factor, and defining characteristics
The three-part nursing diagnosis label consists of the NANDA-I label, related factor, and defining
characteristics. This format is also known as the problem, etiology, and symptoms (PES) format.
