Chapter 17 Nursing Diagnosis | Questions with 100% Verified
Answers | Latest Update 2026/2027
Question: After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the
rationale for the nurse's actions? a. To form a language that can be encoded only by nurses b. To distinguish
the nurse's role from the physician's role c. To develop clinical judgment based on other's intuition d. To help
nurses focus on the scope of medical practice
Answer: B (The standard formal nursing diagnosis serves several purposes. Nursing diagnoses distinguish the
nurse's role from that of the physician/health care provider and help nurses focus on the scope of nursing
practice (not medical) while fostering the development of nursing knowledge. A nursing diagnosis 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 judgment based on information.)
Question: Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved? a. Sore
throat b. Acute pain c. Sleep apnea d. Heart failure
Answer: B (Acute pain is the only NANDA-I approved diagnosis listed. Sleep apnea and heart failure are medical
diagnoses, and sore throat is subjective data.)
Question: A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia
with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write? a. Ineffective
breathing pattern related to pneumonia b. Risk for infection related to chest x-ray procedure c. Risk for
deficient fluid volume related to dehydration d. Impaired gas exchange related to alveolar-capillary membrane
changes
Answer: D (The related to factor of alveolar-capillary membrane changes is accurately written 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 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 test or a chronic
dysfunction is not an etiology or a condition that a nursing intervention is able to treat.)
Question: The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement,
Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part
of the diagnostic statement does the nurse need to revise? a. Etiology b. Nursing diagnosis c. Collaborative
problem d. Defining characteristic
Answer: A (The etiology, or related to factor, of tibial fracture is a medical diagnosis and needs to be revised.
The nursing diagnosis is appropriate because the patient is unable to ambulate. A collaborative problem is an
actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's
health status; there is no collaborative problem listed. The defining characteristic (subjective and objective
data that support the diagnosis) is appropriate for Impaired physical mobility.)
Question: A nurse is using assessment data gathered about a patient and combining critical thinking to
develop a nursing diagnosis. What is the nurse doing? a. Assigning clinical cues b. Defining characteristics c.
Diagnostic reasoning d. Diagnostic labeling
Answer: C (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 nursing diagnosis. Defining characteristics are
assessment findings that support the nursing diagnosis. Defining characteristics are the subjective and
objective clinical cues, which a nurse gathers intentionally and unintentionally. The nurse 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.)
, Question: A patient presents to the emergency department following a motor vehicle crash and suffers a right
femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in
good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse
will include in the plan of care? a. Posttrauma syndrome b. Constipation c. Acute pain d. Anxiety
Answer: C (Based on the assessment data provided, the only supportive evidence for one of the diagnosis
options is "Reports only moderate discomfort," which would support Acute pain. No supportive evidence is
provided for any of the other diagnoses. The patient may indeed develop signs or symptoms of the other
problems, but supportive data are presently lacking in the provided information.)
Question: The nurse is reviewing a patient's database for significant changes and discovers that the patient
has not voided in over 8 hours. The patient's kidney function lab results are abnormal, and the patient's oral
intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse
proceed to after this review? a. Diagnosis b. Planning c. Implementation d. Evaluation
Answer: A (After a thorough assessment, the nurse should proceed to analyzing the data and formulating a
nursing diagnosis before proceeding with developing the plan of care and determining appropriate
interventions; this is the diagnosis phase. The evaluation phase involves determining whether the goals were
met and interventions were effective.)
Question: A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning
self-catheterization versus assisted catheterization by home health nurses and family members. The nurse
adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?
a. Risk b. Problem focused c. Health promotion d. Collaborative problem
Answer: C (A health promotion nursing diagnosis is a clinical judgment concerning motivation and desire to
increase well-being and actualize human health potential. A problem-focused nursing diagnosis describes a
clinical judgment concerning an undesirable human response to a health condition/life process that exists in an
individual, family, or community. A risk nursing diagnosis is a clinical judgment concerning the vulnerability of
an individual, family, group or community for developing an undesirable human response to health
conditions/life processes. A collaborative problem is an actual or potential physiological complication that
nurses monitor to detect the onset of changes in a patient's health status.)
Question: A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The
nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure was low when it
was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient
begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even
lower. In which phase of the nursing process did the nurse first make an error? a. Assessment b. Diagnosis c.
Implementation d. Evaluation
Answer: A (The diagnostic process should flow from the assessment. In this case, the nurse should have
assessed the patient's blood pressure before giving the medication. The nurse could have prevented the
patient's untoward reaction if the low blood pressure was assessed first. Diagnosis follows assessment.
Administering the medication occurs in implementation, but this is not the first error. There are no errors in
evaluation.)
Question: A nurse adds the following diagnosis to a patient's care plan: Constipation related to decreased
gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no
bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write
as the defining characteristic? a. Decreased gastrointestinal motility b. Pain medication c. Abdominal distention
d. Constipation
Answer: C (Abdominal distention, no reported bowel movement, and abdominal pain are the defining
characteristics. Decreased gastrointestinal motility secondary to pain medication is an etiology or related to
factor. Constipation (problem or NANDA-1 diagnosis) is the identified problem derived from the defining
characteristics.)
Answers | Latest Update 2026/2027
Question: After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the
rationale for the nurse's actions? a. To form a language that can be encoded only by nurses b. To distinguish
the nurse's role from the physician's role c. To develop clinical judgment based on other's intuition d. To help
nurses focus on the scope of medical practice
Answer: B (The standard formal nursing diagnosis serves several purposes. Nursing diagnoses distinguish the
nurse's role from that of the physician/health care provider and help nurses focus on the scope of nursing
practice (not medical) while fostering the development of nursing knowledge. A nursing diagnosis 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 judgment based on information.)
Question: Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved? a. Sore
throat b. Acute pain c. Sleep apnea d. Heart failure
Answer: B (Acute pain is the only NANDA-I approved diagnosis listed. Sleep apnea and heart failure are medical
diagnoses, and sore throat is subjective data.)
Question: A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia
with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write? a. Ineffective
breathing pattern related to pneumonia b. Risk for infection related to chest x-ray procedure c. Risk for
deficient fluid volume related to dehydration d. Impaired gas exchange related to alveolar-capillary membrane
changes
Answer: D (The related to factor of alveolar-capillary membrane changes is accurately written 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 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 test or a chronic
dysfunction is not an etiology or a condition that a nursing intervention is able to treat.)
Question: The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement,
Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part
of the diagnostic statement does the nurse need to revise? a. Etiology b. Nursing diagnosis c. Collaborative
problem d. Defining characteristic
Answer: A (The etiology, or related to factor, of tibial fracture is a medical diagnosis and needs to be revised.
The nursing diagnosis is appropriate because the patient is unable to ambulate. A collaborative problem is an
actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's
health status; there is no collaborative problem listed. The defining characteristic (subjective and objective
data that support the diagnosis) is appropriate for Impaired physical mobility.)
Question: A nurse is using assessment data gathered about a patient and combining critical thinking to
develop a nursing diagnosis. What is the nurse doing? a. Assigning clinical cues b. Defining characteristics c.
Diagnostic reasoning d. Diagnostic labeling
Answer: C (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 nursing diagnosis. Defining characteristics are
assessment findings that support the nursing diagnosis. Defining characteristics are the subjective and
objective clinical cues, which a nurse gathers intentionally and unintentionally. The nurse 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.)
, Question: A patient presents to the emergency department following a motor vehicle crash and suffers a right
femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in
good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse
will include in the plan of care? a. Posttrauma syndrome b. Constipation c. Acute pain d. Anxiety
Answer: C (Based on the assessment data provided, the only supportive evidence for one of the diagnosis
options is "Reports only moderate discomfort," which would support Acute pain. No supportive evidence is
provided for any of the other diagnoses. The patient may indeed develop signs or symptoms of the other
problems, but supportive data are presently lacking in the provided information.)
Question: The nurse is reviewing a patient's database for significant changes and discovers that the patient
has not voided in over 8 hours. The patient's kidney function lab results are abnormal, and the patient's oral
intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse
proceed to after this review? a. Diagnosis b. Planning c. Implementation d. Evaluation
Answer: A (After a thorough assessment, the nurse should proceed to analyzing the data and formulating a
nursing diagnosis before proceeding with developing the plan of care and determining appropriate
interventions; this is the diagnosis phase. The evaluation phase involves determining whether the goals were
met and interventions were effective.)
Question: A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning
self-catheterization versus assisted catheterization by home health nurses and family members. The nurse
adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?
a. Risk b. Problem focused c. Health promotion d. Collaborative problem
Answer: C (A health promotion nursing diagnosis is a clinical judgment concerning motivation and desire to
increase well-being and actualize human health potential. A problem-focused nursing diagnosis describes a
clinical judgment concerning an undesirable human response to a health condition/life process that exists in an
individual, family, or community. A risk nursing diagnosis is a clinical judgment concerning the vulnerability of
an individual, family, group or community for developing an undesirable human response to health
conditions/life processes. A collaborative problem is an actual or potential physiological complication that
nurses monitor to detect the onset of changes in a patient's health status.)
Question: A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The
nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure was low when it
was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient
begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even
lower. In which phase of the nursing process did the nurse first make an error? a. Assessment b. Diagnosis c.
Implementation d. Evaluation
Answer: A (The diagnostic process should flow from the assessment. In this case, the nurse should have
assessed the patient's blood pressure before giving the medication. The nurse could have prevented the
patient's untoward reaction if the low blood pressure was assessed first. Diagnosis follows assessment.
Administering the medication occurs in implementation, but this is not the first error. There are no errors in
evaluation.)
Question: A nurse adds the following diagnosis to a patient's care plan: Constipation related to decreased
gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no
bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write
as the defining characteristic? a. Decreased gastrointestinal motility b. Pain medication c. Abdominal distention
d. Constipation
Answer: C (Abdominal distention, no reported bowel movement, and abdominal pain are the defining
characteristics. Decreased gastrointestinal motility secondary to pain medication is an etiology or related to
factor. Constipation (problem or NANDA-1 diagnosis) is the identified problem derived from the defining
characteristics.)
