Chapter 17 Practice Test: Nursing Diagnosis UPDATED
ACTUAL Questions and CORRECT Answers
1. After assessing a patient, a nurse develops a standard ANS: B
formal nursing diagnosis. What is the rationale for the
nurse's actions? The standard formal nursing diagnosis serves several purposes. Nursing
diagnoses distinguish the nurse's role from that of the physician/health care
a.To form a language that can be encoded only by nurses provider and help nurses focus on the scope of nursing practice (not medical)
while fostering the development of nursing knowledge. A nursing diagnosis
b.To distinguish the nurse's role from the physician's role 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
c.To develop clinical judgment based on other's intuition judgment based on information.
d.To help nurses focus on the scope of medical practice
2. Which diagnosis will the nurse document in a patient's ANS: B
care plan that is NANDA-I approved?
Acute pain is the only NANDA-I approved diagnosis listed. Sleep apnea and heart
a. Sore throat failure are medical diagnoses, and sore throat is subjective data.
b. Acute pain
c. Sleep apnea
d. Heart failure
, 3. A nurse develops a nursing diagnostic statement for a ANS: D
patient with a medical diagnosis of pneumonia with chest
x-ray results of lower lobe infiltrates. Which nursing The related to factor of alveolar-capillary membrane changes is accurately written
diagnosis did the nurse write? because it is a patient response to the disease process of pneumonia that the
nurse can treat. The related to factor should be the cause of the problem (nursing
a.Ineffective breathing pattern related to pneumonia 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
b.Risk for infection related to chest x-ray procedure test or a chronic dysfunction is not an etiology or a condition that a nursing
intervention is able to treat.
c.Risk for deficient fluid volume related to dehydration
d.Impaired gas exchange related to alveolar-capillary
membrane changes
4. The nurse is reviewing a patient's plan of care, which ANS: A
includes the nursing diagnostic statement, Impaired
physical mobility related to tibial fracture as evidenced The etiology, or related to factor, of tibial fracture is a medical diagnosis and
by patient's inability to ambulate. Which part of the needs to be revised. The nursing diagnosis is appropriate because the patient is
diagnostic statement does the nurse need to revise? unable to ambulate. A collaborative problem is an actual or potential
physiological complication that nurses monitor to detect the onset of changes in a
a. Etiology patient's health status; there is no collaborative problem listed. The defining
b. Nursing diagnosis characteristic (subjective and objective data that support the diagnosis) is
c. Collaborative problem appropriate for Impaired physical mobility.
d.Defining characteristic
5. A nurse is using assessment data gathered about a ANS: C
patient and combining critical thinking to develop a
nursing diagnosis. What is the nurse doing? Diagnostic reasoning is defined as a process of using the assessment data
gathered about a patient to logically explain a clinical judgment, in this case a
a. Assigning clinical cues nursing diagnosis. Defining characteristics are assessment findings that support
b. Defining characteristics the nursing diagnosis. Defining characteristics are the subjective and objective
c. Diagnostic reasoning clinical cues, which a nurse gathers intentionally and unintentionally. The nurse
d. Diagnostic labeling organizes all of the patient's data into meaningful and usable data clusters, which
lead to a diagnostic conclusion. Diagnostic labeling is simply the name of the
diagnosis.
6. A patient presents to the emergency department ANS: C
following a motor vehicle crash and suffers a right femur
fracture. The leg is stabilized in a full leg cast. Otherwise, Based on the assessment data provided, the only supportive evidence for one of
the patient has no other major injuries, is in good health, the diagnosis options is "Reports only moderate discomfort," which would
and reports only moderate discomfort. Which is the most support Acute pain. No supportive evidence is provided for any of the other
pertinent nursing diagnosis the nurse will include in the diagnoses. The patient may indeed develop signs or symptoms of the other
plan of care? problems, but supportive data are presently lacking in the provided information.
a.Posttrauma syndrome
b.Constipation
c.Acute pain
d.Anxiety
ACTUAL Questions and CORRECT Answers
1. After assessing a patient, a nurse develops a standard ANS: B
formal nursing diagnosis. What is the rationale for the
nurse's actions? The standard formal nursing diagnosis serves several purposes. Nursing
diagnoses distinguish the nurse's role from that of the physician/health care
a.To form a language that can be encoded only by nurses provider and help nurses focus on the scope of nursing practice (not medical)
while fostering the development of nursing knowledge. A nursing diagnosis
b.To distinguish the nurse's role from the physician's role 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
c.To develop clinical judgment based on other's intuition judgment based on information.
d.To help nurses focus on the scope of medical practice
2. Which diagnosis will the nurse document in a patient's ANS: B
care plan that is NANDA-I approved?
Acute pain is the only NANDA-I approved diagnosis listed. Sleep apnea and heart
a. Sore throat failure are medical diagnoses, and sore throat is subjective data.
b. Acute pain
c. Sleep apnea
d. Heart failure
, 3. A nurse develops a nursing diagnostic statement for a ANS: D
patient with a medical diagnosis of pneumonia with chest
x-ray results of lower lobe infiltrates. Which nursing The related to factor of alveolar-capillary membrane changes is accurately written
diagnosis did the nurse write? because it is a patient response to the disease process of pneumonia that the
nurse can treat. The related to factor should be the cause of the problem (nursing
a.Ineffective breathing pattern related to pneumonia 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
b.Risk for infection related to chest x-ray procedure test or a chronic dysfunction is not an etiology or a condition that a nursing
intervention is able to treat.
c.Risk for deficient fluid volume related to dehydration
d.Impaired gas exchange related to alveolar-capillary
membrane changes
4. The nurse is reviewing a patient's plan of care, which ANS: A
includes the nursing diagnostic statement, Impaired
physical mobility related to tibial fracture as evidenced The etiology, or related to factor, of tibial fracture is a medical diagnosis and
by patient's inability to ambulate. Which part of the needs to be revised. The nursing diagnosis is appropriate because the patient is
diagnostic statement does the nurse need to revise? unable to ambulate. A collaborative problem is an actual or potential
physiological complication that nurses monitor to detect the onset of changes in a
a. Etiology patient's health status; there is no collaborative problem listed. The defining
b. Nursing diagnosis characteristic (subjective and objective data that support the diagnosis) is
c. Collaborative problem appropriate for Impaired physical mobility.
d.Defining characteristic
5. A nurse is using assessment data gathered about a ANS: C
patient and combining critical thinking to develop a
nursing diagnosis. What is the nurse doing? Diagnostic reasoning is defined as a process of using the assessment data
gathered about a patient to logically explain a clinical judgment, in this case a
a. Assigning clinical cues nursing diagnosis. Defining characteristics are assessment findings that support
b. Defining characteristics the nursing diagnosis. Defining characteristics are the subjective and objective
c. Diagnostic reasoning clinical cues, which a nurse gathers intentionally and unintentionally. The nurse
d. Diagnostic labeling organizes all of the patient's data into meaningful and usable data clusters, which
lead to a diagnostic conclusion. Diagnostic labeling is simply the name of the
diagnosis.
6. A patient presents to the emergency department ANS: C
following a motor vehicle crash and suffers a right femur
fracture. The leg is stabilized in a full leg cast. Otherwise, Based on the assessment data provided, the only supportive evidence for one of
the patient has no other major injuries, is in good health, the diagnosis options is "Reports only moderate discomfort," which would
and reports only moderate discomfort. Which is the most support Acute pain. No supportive evidence is provided for any of the other
pertinent nursing diagnosis the nurse will include in the diagnoses. The patient may indeed develop signs or symptoms of the other
plan of care? problems, but supportive data are presently lacking in the provided information.
a.Posttrauma syndrome
b.Constipation
c.Acute pain
d.Anxiety
