C HAPTER 17: N URSING D IAGNOSIS
Fundamentals of Nursing 10th Edition; Potter Perry
MULTIPLE CHOICE
1. When asked to define Nursing Diagnosis the nurses best response is:
A. It is the second step in the Nursing Process.
B. It is the process of defining a clients problems.
C. It correlates a clients problem with a condition a nurse is competent
to treat.
D. It focuses care a licensed nurse can provide with the identified
needs of a client.
ANS: C
It correlates a clients problem with a condition a nurse is competent to
treat is a statement that describes the clients actual or potential
response to a health problem that the nurse is licensed and competent
to treat. Although It is the second step in the Nursing Process is true, it
does not define the term. Although It is the process of defining a
clients problems is true, is does not address the nursing aspect of the
term. Although It focuses care a licensed nurse can provide with the
identified needs of a client is true, the focus is not primaril y on care.
DIF: C dm 248 OBJ: Anal ysis TOP: Nursing Process: Diagnosis
MSC: NC LEX test plan designation: Health Promotion and
Maintenance
,2. The nurses initial responsibilit y in the management of a clients
collaborative problem is to:
A. Monitor for changes
B. Advocate for the client
C. Implement interventions
D. Evaluate client outcomes
ANS: A
Nurses initiall y monitor to detect the onset of changes in a clients
status. Although advocating for the client is a nursing role, it is not
reserved exclusivel y to collaborative problems. Implement
interventions is not the initial responsibilit y. Evaluate client outcomes
is not the initial responsibilit y.
DIF: C dm 248 OBJ: Comprehension TOP: Nursing Process:
Diagnosis MSC: NC LEX test plan designation: Health
Promotion and Maintenance
3. The nurse has identified deficient knowledge regarding surgery for a
client who is scheduled for an outpatient procedure. Which of the
following instructional topics will best minimize the clients anxiet y
regarding the procedure?
A. Assure the client that preoperative sedation will be administered.
B. Discuss the pre - and post-procedure care that will be provided.
C. Provide a detailed explanation of why the procedure is necessary.
D. Guarantee that family will be regularl y updated during the
procedure.
ANS: B
, A nursing diagnosis focuses on a clients actual or potential response to
a health problem rather than on the physiological event, complications,
or disease. In the case of the diagnosis deficient knowledge regarding
surgery, the nurse will best minimize anxiet y by providing information
regarding pre - and postoperative routines so as to facilitate the client
in formulating realistic expectations. Although the other options are
appropriate, they are limited in scope and do not have as much impact
on anxiet y.
DIF: C dm 249 OBJ: Anal ysis TOP: Nursing Process: Diagnosis
MSC: NC LEX test plan designation: Health Promotion and
Maintenance
4. The nursing diagnosis of acute pain falls under which of the following
comfort domain classifications?
A. Social comfort
B. Physical comfort
C. Interpersonal comfort
D. Environmental comfort
ANS: B
There are onl y three classifications for the comfort domain. Acute pain
is a physiological response and so is classified as a physical comfort
problem. Impaired verbal communication is consi dered a social comfort
issue, while at risk for poisoning would be considered an
environmental comfort issue.
Fundamentals of Nursing 10th Edition; Potter Perry
MULTIPLE CHOICE
1. When asked to define Nursing Diagnosis the nurses best response is:
A. It is the second step in the Nursing Process.
B. It is the process of defining a clients problems.
C. It correlates a clients problem with a condition a nurse is competent
to treat.
D. It focuses care a licensed nurse can provide with the identified
needs of a client.
ANS: C
It correlates a clients problem with a condition a nurse is competent to
treat is a statement that describes the clients actual or potential
response to a health problem that the nurse is licensed and competent
to treat. Although It is the second step in the Nursing Process is true, it
does not define the term. Although It is the process of defining a
clients problems is true, is does not address the nursing aspect of the
term. Although It focuses care a licensed nurse can provide with the
identified needs of a client is true, the focus is not primaril y on care.
DIF: C dm 248 OBJ: Anal ysis TOP: Nursing Process: Diagnosis
MSC: NC LEX test plan designation: Health Promotion and
Maintenance
,2. The nurses initial responsibilit y in the management of a clients
collaborative problem is to:
A. Monitor for changes
B. Advocate for the client
C. Implement interventions
D. Evaluate client outcomes
ANS: A
Nurses initiall y monitor to detect the onset of changes in a clients
status. Although advocating for the client is a nursing role, it is not
reserved exclusivel y to collaborative problems. Implement
interventions is not the initial responsibilit y. Evaluate client outcomes
is not the initial responsibilit y.
DIF: C dm 248 OBJ: Comprehension TOP: Nursing Process:
Diagnosis MSC: NC LEX test plan designation: Health
Promotion and Maintenance
3. The nurse has identified deficient knowledge regarding surgery for a
client who is scheduled for an outpatient procedure. Which of the
following instructional topics will best minimize the clients anxiet y
regarding the procedure?
A. Assure the client that preoperative sedation will be administered.
B. Discuss the pre - and post-procedure care that will be provided.
C. Provide a detailed explanation of why the procedure is necessary.
D. Guarantee that family will be regularl y updated during the
procedure.
ANS: B
, A nursing diagnosis focuses on a clients actual or potential response to
a health problem rather than on the physiological event, complications,
or disease. In the case of the diagnosis deficient knowledge regarding
surgery, the nurse will best minimize anxiet y by providing information
regarding pre - and postoperative routines so as to facilitate the client
in formulating realistic expectations. Although the other options are
appropriate, they are limited in scope and do not have as much impact
on anxiet y.
DIF: C dm 249 OBJ: Anal ysis TOP: Nursing Process: Diagnosis
MSC: NC LEX test plan designation: Health Promotion and
Maintenance
4. The nursing diagnosis of acute pain falls under which of the following
comfort domain classifications?
A. Social comfort
B. Physical comfort
C. Interpersonal comfort
D. Environmental comfort
ANS: B
There are onl y three classifications for the comfort domain. Acute pain
is a physiological response and so is classified as a physical comfort
problem. Impaired verbal communication is consi dered a social comfort
issue, while at risk for poisoning would be considered an
environmental comfort issue.
