Chapter 17 Nursing Diagnosis | Questions with 100% Verified
Answers | Latest Update 2026/2027
Question: Following an assessment, the nurse is formulating a nursing diagnosis using the PES format. What
does the "P" in the acronym PES stand for? 1 Period 2 Problem 3 Prevention 4 Predication
Answer: 2 Problem-PES format is a nursing diagnosis in three parts. It includes diagnostic label, etiological
statement, and symptoms or defining characteristics. The "P" stands for problem, the "E" stands for etiology or
related factor, and the "S" stands for symptoms or defining characteristics. The "P" does not stand for period,
prevention, or predication. Test-Taking Tip: Tell yourself, "It will be a PROBLEM on the test if I forget what the P
of PES means." The P of PES stands for problem! Text Reference - p. 230
Question: Which patient-related factors fall under health promotion nursing diagnosis? Select all that apply. A
The patient follows poor hygiene measures. B The patient is willing to consume nutritious foods. C The patient
shows impaired interaction with society. D The patient is ready to enhance his or her coping skills. E The
patient shows readiness to perform regular exercises.
Answer: B-The patient is willing to consume nutritious foods D-The patient is ready to enhance his or her
coping skills E-The patient shows readiness to perform regular exercises. Health promotion nursing diagnosis is
a clinical judgment of a patient's motivation, desire, and readiness to increase well-being. While performing
health promotion nursing diagnoses, the nurse should focus on the patient's readiness to eat nutritious food.
While performing health promotion nursing diagnosis, the nurse should assess the patient's readiness to
enhance coping skills and to perform regular exercise. While performing risk nursing diagnosis, the nurse
should focus on poor hygiene measures of the patient. While performing actual nursing diagnosis, the nurse
should focus on the patient's social interaction ability. Text Reference - p. 228
Question: The nurse completed the following assessment: 63-year-old female client has had abdominal pain for
6 days. She reports not having a bowel movement for 4 days, whereas she normally has a bowel movement
every 2 to 3 days. She has not been hospitalized in the past. Her abdomen is distended. She reports being
anxious about upcoming tests. Her temperature was 37° C, pulse 82 and regular, blood pressure 128/72.
Which of the following data form a cluster, showing a relevant pattern? Select all that apply. 1 Vital sign results
2 Abdominal distention 3 Age of client 4 Change in bowel elimination pattern 5 Abdominal pain 6 No past
history of hospitalization
Answer: 2-Abdominal distention 4-Change In bowel elimination pattern 5-Abdominal pain The presence of
abdominal pain, distention, and a change in bowel elimination pattern forms a cluster , suggesting an
elimination problem. Text Reference - p. 226
Question: What could be the effect of an incorrect nursing diagnosis? 1 It could affect the quality of client care.
2 It would get corrected automatically in the system. 3 It could affect the client's cost of treatment. 4 It could
produce a psychological disorder in the client
Answer: 1-It could affect the quality of client care. An incorrect nursing diagnosis may affect the quality of
client care. Incorrect nursing diagnoses are not corrected automatically in the system. The cost of the client's
care is not dependent on the nursing diagnosis. An incorrect nursing diagnosis would not create a
psychological disorder in the client. Text Reference - p. 232
Question: Which finding would indicate acute pain in a patient? 1 The patient has dilated pupils. 2 The patient
has absence of fatigue signs. 3 The patient does not show fear of reinjury. 4 The patient does not show signs of
depression
Answer: 1-The patient has dilated pupils Pupil dilation is a characteristic of acute pain. Therefore, if the patient
has dilated pupils, it supports the nurse's conclusion. The defining characteristics for chronic pain are signs of
fatigue, fear of reinjury, and depression. The patient does not show these signs; therefore, the patient does not
have chronic pain. Text Reference - p. 227
, Question: Which nursing intervention is most beneficial to a patient who has impaired mobility due to a
musculoskeletal injury in both legs? 1 Immobilizing both legs of the patient for few days 2 Including high-fiber
food in the diet plan of the patient 3 Encouraging active range-of-motion exercises every 2 hours 4 Instructing
the patient to avoid the use of the three-point crutch gait
Answer: 3-Encouraging active range-of-motion exercises every 2 hours Active range-of-motion exercises can
decrease the risk of immobility in the patient with musculoskeletal injury of both legs. Therefore, the patient
with musculoskeletal injury should perform active range-of-motion exercises every 2 hours. Immobilizing both
legs of the patient can further impair the physical mobility in the patient. High-fiber food can prevent the risk of
constipation in the patient but does not reduce the risk of impaired mobility. The patient should be instructed
to use the three-point crutch gait.
Question: What should the nurse focus on when formulating a nursing diagnosis? 1 Disease 2 Complication 3
Physiological event 4 Potential response to a health problem
Answer: 4-Potential response to a health problem A nursing diagnosis focuses on a client's potential response
to a health problem. A nursing diagnosis provides a basis for selecting, planning, and implementing
interventions. Diseases, complications, and physiological events are not the focus of formulating the nursing
diagnosis. These components are part of a medical diagnosis. Text Reference - p. 227
Question: A nurse is teaching nursing students about nursing diagnoses. What does the nurse consider as a
nursing diagnosis? Select all that apply. 1 Nausea 2 Pneumonia 3 Acute pain 4 Osteoarthritis 5 Diabetes
mellitus
Answer: 1-Nausea 3-Acute pain Nausea and acute pain are nursing diagnoses. These problems can be easily
identified by observing the client's signs and symptoms. They do not require any specific diagnostic test. These
problems can be easily treated by the nurse. Pneumonia, osteoarthritis, and diabetes mellitus are medical
diagnoses. They require specific diagnostic tests to be confirmed. They are diagnosed by the primary
healthcare provider. Text Reference - p. 222
Question: A group of nursing students are being taught about the different types of nursing diagnosis. Which
ones are examples of health promotion nursing diagnoses? Select all that apply. 1 Readiness for enhanced
family coping 2 Acute pain 3 Wandering 4 Readiness for enhanced nutrition 5 Stress urinary incontinence
Answer: 1-Readiness for enhanced family coping 4-Readiness for enhanced nutrition A health promotion
nursing diagnosis is a clinical judgment. The clinical judgment can be of a person's, family's, or community's
motivation, desire, and readiness to increase wellbeing and actualize human health potential. It is expressed in
their readiness to enhance specific health behaviors such as nutrition and exercise. Acute pain, wandering, and
stress urinary incontinence are examples of actual nursing diagnosis. Actual nursing diagnoses are human
responses to health conditions or life processes pg.228
Question: What should the nurse do if he or she finds that a patient is anxious due to a job loss? Select all that
apply. A Encourage patient to continue exercise routine. B Instruct the patient to remain alone for few days. C
Instruct the family to limit conversation with the patient. D Ensure communication between the patient and
social worker. E Administer intravenous fluids and electrolytes to the patient
Answer: Encourage patient to continue exercise routine D-Ensure communication between the patient and
social worker The patient who is anxious due to a job loss requires counseling on health promotion tips.
Therefore, the nurse should encourage the patient to continue with exercises to help the patient reduce
anxiety. Social workers give counseling regarding a job; therefore, the nurse should encourage communication
between the patient and social worker. Remaining alone can further increase the risk of anxiety in the patient.
Limiting conversation can keep the patient in emotional distress. Intravenous fluids and electrolytes do not
reduce anxiety in the patient. Therefore, there is no need of administering intravenous fluids and electrolytes
to the patient in this situation. Text Reference - p. 229
Answers | Latest Update 2026/2027
Question: Following an assessment, the nurse is formulating a nursing diagnosis using the PES format. What
does the "P" in the acronym PES stand for? 1 Period 2 Problem 3 Prevention 4 Predication
Answer: 2 Problem-PES format is a nursing diagnosis in three parts. It includes diagnostic label, etiological
statement, and symptoms or defining characteristics. The "P" stands for problem, the "E" stands for etiology or
related factor, and the "S" stands for symptoms or defining characteristics. The "P" does not stand for period,
prevention, or predication. Test-Taking Tip: Tell yourself, "It will be a PROBLEM on the test if I forget what the P
of PES means." The P of PES stands for problem! Text Reference - p. 230
Question: Which patient-related factors fall under health promotion nursing diagnosis? Select all that apply. A
The patient follows poor hygiene measures. B The patient is willing to consume nutritious foods. C The patient
shows impaired interaction with society. D The patient is ready to enhance his or her coping skills. E The
patient shows readiness to perform regular exercises.
Answer: B-The patient is willing to consume nutritious foods D-The patient is ready to enhance his or her
coping skills E-The patient shows readiness to perform regular exercises. Health promotion nursing diagnosis is
a clinical judgment of a patient's motivation, desire, and readiness to increase well-being. While performing
health promotion nursing diagnoses, the nurse should focus on the patient's readiness to eat nutritious food.
While performing health promotion nursing diagnosis, the nurse should assess the patient's readiness to
enhance coping skills and to perform regular exercise. While performing risk nursing diagnosis, the nurse
should focus on poor hygiene measures of the patient. While performing actual nursing diagnosis, the nurse
should focus on the patient's social interaction ability. Text Reference - p. 228
Question: The nurse completed the following assessment: 63-year-old female client has had abdominal pain for
6 days. She reports not having a bowel movement for 4 days, whereas she normally has a bowel movement
every 2 to 3 days. She has not been hospitalized in the past. Her abdomen is distended. She reports being
anxious about upcoming tests. Her temperature was 37° C, pulse 82 and regular, blood pressure 128/72.
Which of the following data form a cluster, showing a relevant pattern? Select all that apply. 1 Vital sign results
2 Abdominal distention 3 Age of client 4 Change in bowel elimination pattern 5 Abdominal pain 6 No past
history of hospitalization
Answer: 2-Abdominal distention 4-Change In bowel elimination pattern 5-Abdominal pain The presence of
abdominal pain, distention, and a change in bowel elimination pattern forms a cluster , suggesting an
elimination problem. Text Reference - p. 226
Question: What could be the effect of an incorrect nursing diagnosis? 1 It could affect the quality of client care.
2 It would get corrected automatically in the system. 3 It could affect the client's cost of treatment. 4 It could
produce a psychological disorder in the client
Answer: 1-It could affect the quality of client care. An incorrect nursing diagnosis may affect the quality of
client care. Incorrect nursing diagnoses are not corrected automatically in the system. The cost of the client's
care is not dependent on the nursing diagnosis. An incorrect nursing diagnosis would not create a
psychological disorder in the client. Text Reference - p. 232
Question: Which finding would indicate acute pain in a patient? 1 The patient has dilated pupils. 2 The patient
has absence of fatigue signs. 3 The patient does not show fear of reinjury. 4 The patient does not show signs of
depression
Answer: 1-The patient has dilated pupils Pupil dilation is a characteristic of acute pain. Therefore, if the patient
has dilated pupils, it supports the nurse's conclusion. The defining characteristics for chronic pain are signs of
fatigue, fear of reinjury, and depression. The patient does not show these signs; therefore, the patient does not
have chronic pain. Text Reference - p. 227
, Question: Which nursing intervention is most beneficial to a patient who has impaired mobility due to a
musculoskeletal injury in both legs? 1 Immobilizing both legs of the patient for few days 2 Including high-fiber
food in the diet plan of the patient 3 Encouraging active range-of-motion exercises every 2 hours 4 Instructing
the patient to avoid the use of the three-point crutch gait
Answer: 3-Encouraging active range-of-motion exercises every 2 hours Active range-of-motion exercises can
decrease the risk of immobility in the patient with musculoskeletal injury of both legs. Therefore, the patient
with musculoskeletal injury should perform active range-of-motion exercises every 2 hours. Immobilizing both
legs of the patient can further impair the physical mobility in the patient. High-fiber food can prevent the risk of
constipation in the patient but does not reduce the risk of impaired mobility. The patient should be instructed
to use the three-point crutch gait.
Question: What should the nurse focus on when formulating a nursing diagnosis? 1 Disease 2 Complication 3
Physiological event 4 Potential response to a health problem
Answer: 4-Potential response to a health problem A nursing diagnosis focuses on a client's potential response
to a health problem. A nursing diagnosis provides a basis for selecting, planning, and implementing
interventions. Diseases, complications, and physiological events are not the focus of formulating the nursing
diagnosis. These components are part of a medical diagnosis. Text Reference - p. 227
Question: A nurse is teaching nursing students about nursing diagnoses. What does the nurse consider as a
nursing diagnosis? Select all that apply. 1 Nausea 2 Pneumonia 3 Acute pain 4 Osteoarthritis 5 Diabetes
mellitus
Answer: 1-Nausea 3-Acute pain Nausea and acute pain are nursing diagnoses. These problems can be easily
identified by observing the client's signs and symptoms. They do not require any specific diagnostic test. These
problems can be easily treated by the nurse. Pneumonia, osteoarthritis, and diabetes mellitus are medical
diagnoses. They require specific diagnostic tests to be confirmed. They are diagnosed by the primary
healthcare provider. Text Reference - p. 222
Question: A group of nursing students are being taught about the different types of nursing diagnosis. Which
ones are examples of health promotion nursing diagnoses? Select all that apply. 1 Readiness for enhanced
family coping 2 Acute pain 3 Wandering 4 Readiness for enhanced nutrition 5 Stress urinary incontinence
Answer: 1-Readiness for enhanced family coping 4-Readiness for enhanced nutrition A health promotion
nursing diagnosis is a clinical judgment. The clinical judgment can be of a person's, family's, or community's
motivation, desire, and readiness to increase wellbeing and actualize human health potential. It is expressed in
their readiness to enhance specific health behaviors such as nutrition and exercise. Acute pain, wandering, and
stress urinary incontinence are examples of actual nursing diagnosis. Actual nursing diagnoses are human
responses to health conditions or life processes pg.228
Question: What should the nurse do if he or she finds that a patient is anxious due to a job loss? Select all that
apply. A Encourage patient to continue exercise routine. B Instruct the patient to remain alone for few days. C
Instruct the family to limit conversation with the patient. D Ensure communication between the patient and
social worker. E Administer intravenous fluids and electrolytes to the patient
Answer: Encourage patient to continue exercise routine D-Ensure communication between the patient and
social worker The patient who is anxious due to a job loss requires counseling on health promotion tips.
Therefore, the nurse should encourage the patient to continue with exercises to help the patient reduce
anxiety. Social workers give counseling regarding a job; therefore, the nurse should encourage communication
between the patient and social worker. Remaining alone can further increase the risk of anxiety in the patient.
Limiting conversation can keep the patient in emotional distress. Intravenous fluids and electrolytes do not
reduce anxiety in the patient. Therefore, there is no need of administering intravenous fluids and electrolytes
to the patient in this situation. Text Reference - p. 229
