Nursing Diagnosis – Questions With Fully Solved
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Terms in this set (41)
The nursing diagnosis Impaired B
Parenting related to mother's
developmental delay is an example of This is an example of a problem-focused nursing
a(n): diagnosis with a related factor, based on NANDA-I
diagnostic terminology. Most health promotion
A. Risk nursing diagnosis. diagnoses do not have established related factors
B. Problem-focused nursing diagnosis. based on NANDA-I; their use is optional. Wellness
C. Health promotion nursing diagnoses are not one of the types of NANDA-I
diagnosis. diagnoses.
D. Wellness nursing diagnosis.
A nurse interviewed and conducted a D
physical examination of a patient.
Among the assessment data the nurse A data cluster is a set of cues (i.e., the signs or
gathered were an increased symptoms gathered during assessment).
respiratory rate, the patient reporting
difficulty breathing while lying flat,
and pursed-lip breathing. This data set
is an example of:
A. Collaborative data set.
B. Diagnostic label.
C. Related factors.
D. Data cluster.
,A nurse is reviewing a patient's list of D
nursing diagnoses in the medical
record. The most recent nursing Intestinal colitis is a medical diagnosis. The related
diagnosis is Diarrhea related to factor in a nursing diagnostic statement is always
intestinal colitis. For which of the within the domain of nursing practice and a condition
following reasons is this an incorrectly that responds to nursing interventions. Nursing
stated diagnostic statement? interventions do not change a medical diagnosis.
A. Identifying the clinical sign instead
of an etiology
B. Identifying a diagnosis on the basis
of prejudicial judgment
C. Identifying the diagnostic study
rather than a problem caused by the
diagnostic study
D. Identifying the medical diagnosis
instead of the patient's response to
the diagnosis.
A nurse is assigned to a new patient A
admitted to the nursing unit following
admission through the emergency This is the correct steps for making a nursing
department. The nurse collects a diagnosis.
nursing history and interviews the
patient. What are the steps for making
a nursing diagnosis in the correct
order, beginning with the first step?
1. Considers context of patient's health
problem and selects a related factor
2. Reviews assessment data, noting
objective and subjective clinical
information
3. Clusters clinical cues that form a
pattern
4. Chooses diagnostic label
A. 2, 3, 4, 1
B. 3, 2, 4, 1
C. 2, 3, 1, 4
D. 1, 4, 3, 2
, A nursing student reports to a lead C
charge nurse that his assigned patient
seems to be less alert and his blood It is likely the charge nurse suspects that the student
pressure is lower, dropping from has not collected enough cues to support the
140/80 to 110/60. The nursing student diagnosis. A change in blood pressure and mental
states, "I believe this is a nursing status changes are significant findings that can be
diagnosis of Deficient Fluid Volume." attributed to fluid volume excess and other
The lead charge nurse immediately diagnoses. The recommendation of the symptom
goes to the patient's room with the cluster by the registered nurse would allow the
student to assess the patient's student to have sufficient data to confirm a deficient
orientation, heart rate, skin turgor, and fluid volume.
urine output for last 8 hours. The lead
charge nurse suspects that the
student has made which type of
diagnostic error?
A. Insufficient cluster of cues
B. Disorganization
C. Insufficient number of cues
D. Evidence that another diagnosis is
more likely
A nurse in a mother-baby clinic learns C
that a 16-year-old has given birth to
her first child and has not been to a In this scenario the related factor is the mother's
well-baby class yet. The nurse's deficient knowledge. A related factor is a condition,
assessment reveals that the infant historical factor, or etiology that gives a context for
cries when breastfeeding and has the defining characteristics, in this case the infant
difficulty latching on to the nipple. The crying, inability to latch on to breast, and absent
infant has not gained weight over the weight gain.
last 2 weeks. The nurse identifies the
patient's nursing diagnosis as
Ineffective Breastfeeding. Which of
the following is the best "related to"
factor?
A. Infant crying at breast
B. Infant unable to latch on to breast
correctly
C. Mother's deficient knowledge
D. Lack of infant weight gain
Solutions
Save
Terms in this set (41)
The nursing diagnosis Impaired B
Parenting related to mother's
developmental delay is an example of This is an example of a problem-focused nursing
a(n): diagnosis with a related factor, based on NANDA-I
diagnostic terminology. Most health promotion
A. Risk nursing diagnosis. diagnoses do not have established related factors
B. Problem-focused nursing diagnosis. based on NANDA-I; their use is optional. Wellness
C. Health promotion nursing diagnoses are not one of the types of NANDA-I
diagnosis. diagnoses.
D. Wellness nursing diagnosis.
A nurse interviewed and conducted a D
physical examination of a patient.
Among the assessment data the nurse A data cluster is a set of cues (i.e., the signs or
gathered were an increased symptoms gathered during assessment).
respiratory rate, the patient reporting
difficulty breathing while lying flat,
and pursed-lip breathing. This data set
is an example of:
A. Collaborative data set.
B. Diagnostic label.
C. Related factors.
D. Data cluster.
,A nurse is reviewing a patient's list of D
nursing diagnoses in the medical
record. The most recent nursing Intestinal colitis is a medical diagnosis. The related
diagnosis is Diarrhea related to factor in a nursing diagnostic statement is always
intestinal colitis. For which of the within the domain of nursing practice and a condition
following reasons is this an incorrectly that responds to nursing interventions. Nursing
stated diagnostic statement? interventions do not change a medical diagnosis.
A. Identifying the clinical sign instead
of an etiology
B. Identifying a diagnosis on the basis
of prejudicial judgment
C. Identifying the diagnostic study
rather than a problem caused by the
diagnostic study
D. Identifying the medical diagnosis
instead of the patient's response to
the diagnosis.
A nurse is assigned to a new patient A
admitted to the nursing unit following
admission through the emergency This is the correct steps for making a nursing
department. The nurse collects a diagnosis.
nursing history and interviews the
patient. What are the steps for making
a nursing diagnosis in the correct
order, beginning with the first step?
1. Considers context of patient's health
problem and selects a related factor
2. Reviews assessment data, noting
objective and subjective clinical
information
3. Clusters clinical cues that form a
pattern
4. Chooses diagnostic label
A. 2, 3, 4, 1
B. 3, 2, 4, 1
C. 2, 3, 1, 4
D. 1, 4, 3, 2
, A nursing student reports to a lead C
charge nurse that his assigned patient
seems to be less alert and his blood It is likely the charge nurse suspects that the student
pressure is lower, dropping from has not collected enough cues to support the
140/80 to 110/60. The nursing student diagnosis. A change in blood pressure and mental
states, "I believe this is a nursing status changes are significant findings that can be
diagnosis of Deficient Fluid Volume." attributed to fluid volume excess and other
The lead charge nurse immediately diagnoses. The recommendation of the symptom
goes to the patient's room with the cluster by the registered nurse would allow the
student to assess the patient's student to have sufficient data to confirm a deficient
orientation, heart rate, skin turgor, and fluid volume.
urine output for last 8 hours. The lead
charge nurse suspects that the
student has made which type of
diagnostic error?
A. Insufficient cluster of cues
B. Disorganization
C. Insufficient number of cues
D. Evidence that another diagnosis is
more likely
A nurse in a mother-baby clinic learns C
that a 16-year-old has given birth to
her first child and has not been to a In this scenario the related factor is the mother's
well-baby class yet. The nurse's deficient knowledge. A related factor is a condition,
assessment reveals that the infant historical factor, or etiology that gives a context for
cries when breastfeeding and has the defining characteristics, in this case the infant
difficulty latching on to the nipple. The crying, inability to latch on to breast, and absent
infant has not gained weight over the weight gain.
last 2 weeks. The nurse identifies the
patient's nursing diagnosis as
Ineffective Breastfeeding. Which of
the following is the best "related to"
factor?
A. Infant crying at breast
B. Infant unable to latch on to breast
correctly
C. Mother's deficient knowledge
D. Lack of infant weight gain
