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Test Bank Diagnostic Questions And Verified
Answers 100% Correct
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 - ANS✔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 - ANS✔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 - ANS✔ANS:
D
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, 2
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 - ANS✔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 - ANS✔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 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.
Defining characteristics - ANS✔Related signs and symptoms or clusters of data that
support the nursing diagnosis. Are the assessment findings that support the nursing
diagnosis. Are the subjective and objective clinical cues which the nurse gather
intentionally or unintentionally.
diagnostic labeling - ANS✔Is simply the name of the diagnosis
diagnostic reasoning process - ANS✔Is define as a process of using assessment data
gathered about a patient to logically explain a clinical judgment, in this case a clinical
diagnosis
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Test Bank Diagnostic Questions And Verified
Answers 100% Correct
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 - ANS✔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 - ANS✔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 - ANS✔ANS:
D
1
, 2
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 - ANS✔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 - ANS✔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 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.
Defining characteristics - ANS✔Related signs and symptoms or clusters of data that
support the nursing diagnosis. Are the assessment findings that support the nursing
diagnosis. Are the subjective and objective clinical cues which the nurse gather
intentionally or unintentionally.
diagnostic labeling - ANS✔Is simply the name of the diagnosis
diagnostic reasoning process - ANS✔Is define as a process of using assessment data
gathered about a patient to logically explain a clinical judgment, in this case a clinical
diagnosis
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