CHAPTER 17 NURSING DIAGNOSIS
FINAL EXAM REVIEW AND PRACTICE
TEST
1. 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: ANS:
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.
2. 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: ANS: 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.
3. 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: ANS: 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.
4. 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: ANS: 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.
5. 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: ANS: 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
FINAL EXAM REVIEW AND PRACTICE
TEST
1. 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: ANS:
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.
2. 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: ANS: 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.
3. 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: ANS: 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.
4. 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: ANS: 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.
5. 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: ANS: 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
