Nursing Diagnosis Chapter 17 :Questions and Answers
A nurse is developing nursing diagnoses for a patient. Beginning with the first step, place in order the steps the
nurse will use.
1. Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma
2. Writes a diagnostic label of impaired gas exchange
3. Organizes data into meaningful clusters
4. Interprets information from patient
5. Writes an etiology
a.
1, 3, 4, 2, 5
b.
1, 3, 4, 5, 2
c.
1, 4, 3, 5, 2
d.
1, 4, 3, 2, 5 - ansA
(The diagnostic process flows from the assessment process (observing and gathering data) and includes
decision-making steps. These steps include data clustering, identifying patient health problems, and
formulating the diagnosis (diagnosis is written as problem or NANDA-I approved diagnosis then etiology or
cause).)
A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge nurse to follow up?
a.
Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous (IV) antibiotics
b.
Completing an interview and physical examination before adding a nursing diagnosis
c.
Developing nursing diagnoses before completing the database
, d.
Including cultural and religious preferences in the database - ansC
(Developing nursing diagnoses before completion of the database needs to be corrected by the charge nurse.
Always identify a nursing diagnosis from the data, not the reverse. The data should be clustered and reviewed
to see if any patterns are present before a nursing diagnosis is assigned. Risk for infection is an appropriate
diagnosis for a patient with an intravenous (IV) site in place. The IV site involves a break in skin integrity and is a
potential source of infection. The diagnostic process should proceed in steps. Completing the interview and
physical examination before adding a nursing diagnosis is appropriate. The patient's cultural background and
developmental stage are important to include in a patient database.)
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 - ansB
(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 paralysis using medical, nursing, and allied health (e.g., physical therapy) interventions. Wandering, urinary
retention, and impaired swallowing are all examples of nursing diagnoses.)
A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse document?
a.
Decreased cardiac output related to altered myocardial contractility.
b.
Patient needs a low-fat diet related to inadequate heart perfusion.
c.
A nurse is developing nursing diagnoses for a patient. Beginning with the first step, place in order the steps the
nurse will use.
1. Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma
2. Writes a diagnostic label of impaired gas exchange
3. Organizes data into meaningful clusters
4. Interprets information from patient
5. Writes an etiology
a.
1, 3, 4, 2, 5
b.
1, 3, 4, 5, 2
c.
1, 4, 3, 5, 2
d.
1, 4, 3, 2, 5 - ansA
(The diagnostic process flows from the assessment process (observing and gathering data) and includes
decision-making steps. These steps include data clustering, identifying patient health problems, and
formulating the diagnosis (diagnosis is written as problem or NANDA-I approved diagnosis then etiology or
cause).)
A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge nurse to follow up?
a.
Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous (IV) antibiotics
b.
Completing an interview and physical examination before adding a nursing diagnosis
c.
Developing nursing diagnoses before completing the database
, d.
Including cultural and religious preferences in the database - ansC
(Developing nursing diagnoses before completion of the database needs to be corrected by the charge nurse.
Always identify a nursing diagnosis from the data, not the reverse. The data should be clustered and reviewed
to see if any patterns are present before a nursing diagnosis is assigned. Risk for infection is an appropriate
diagnosis for a patient with an intravenous (IV) site in place. The IV site involves a break in skin integrity and is a
potential source of infection. The diagnostic process should proceed in steps. Completing the interview and
physical examination before adding a nursing diagnosis is appropriate. The patient's cultural background and
developmental stage are important to include in a patient database.)
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 - ansB
(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 paralysis using medical, nursing, and allied health (e.g., physical therapy) interventions. Wandering, urinary
retention, and impaired swallowing are all examples of nursing diagnoses.)
A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse document?
a.
Decreased cardiac output related to altered myocardial contractility.
b.
Patient needs a low-fat diet related to inadequate heart perfusion.
c.
