Chapter 17 Analysis and Nursing Diagnosis-Fundamentals of Nursing

Chapter 17: Analysis and Nursing Diagnosis
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MULTIPLE CHOICE ra




1. After assessing a hospital client , a nursing attendant develops a standard formal nursing
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diagnosis. What is the rationale for the nursing attendant ’s actions?
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a. To form a language that can be encoded only by nursing attendant s
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b. To determine the direction of nursing care
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c. To develop clinical judgment based on other’s intuition
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d. To help nursing attendant s focus on the scope of medical practice
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ACCURATE ar



ANSWER:-B
The standard formal nursing diagnosis serves several purposes. Nursing diagnoses distinguish t
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he nursing attendant ’s role from that of the physician/health care provider and help nursing a
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ttendant s focus on the scope of nursing practice (not medical) while fostering the developme
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nt of nursing knowledge. A nursing diagnosis provides the precise definition that gives all me
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mbers of the health care team a common language for understanding the hospital client ’s nee
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ds. A diagnosis is a clinical judgment based on information.
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DIF:Understand (comprehension) ra



OBJ:Compare a nursing diagnosis with a medical diagnosis and a collaborative problem. ra ra ra ra ra ra ra ra ra ra ra ar



TOP:Diagnosis MSC: Management of Care ra ra ra




2. Which diagnosis will the nursing attendant document in a hospital client ’s care plan that
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i s NANDA-I approved? a. Sore throat
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b. Acute pain ra




c. Sleep apnea ra



d. Heart failure ra




ACCURATE ar



ANSWER:-B
Acute pain is the only NANDA- ra ra ra ra ra



I approved diagnosis listed. Sleep apnea and heart failure aremedical
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diagnoses, and sore throat is subjective data.
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DIF:Understand (comprehension) ra



OBJ:Compare a nursing diagnosis with a medical diagnosis and a collaborative problem. ra ra ra ra ra ra ra ra ra ra ra ar



TOP:Diagnosis MSC: Management of Care ra ra ra




3. A nursing attendant develops a nursing diagnostic statement for a hospital client with a
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medical diagnosis of pneumonia with chest xray results of lower lobe infiltrates. Which n
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ursing diagnosis did the nursing attendant write?
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a. Ineffective breathing pattern related to pneumonia ra ra ra ra ra




b. Risk for infection related to chest x-ray procedure ra ra ra ra ra ra ra




c. Risk for deficient fluid volume related to dehydration
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d. Impaired gas exchange related to alveolar-capillary membrane changes ra ra ra ra ra ra ra

, ACCURATE ar



ANSWER:-D
The related to factor of alveolarcapillary membrane changes is accurately written because it is a h
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ospital client response to t ra ra ra ra



he disease process of pneumonia that the nursing attendant can treat. The related to factor s
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hould be the cause of the problem (nursing diagnosis) that a nursing attendant can address.
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The related to factors of dehydration and pneumonia are all medical diagnoses that the nursi
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ng attendant cannot change. A diagnostic test or a chronic dysfunction is not an etiology or
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a condition that a nursing intervention is able to treat.
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DIF:Apply (application) ra



OBJ:Explain how the formation of a nursing diagnosis is a factor in clinical judgment. T
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OP:Diagnosis MSC: Management of Care ra ra ra




4. The nursing attendant is reviewing a hospital client ’s plan of care, which includes th
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e ar



nursing diagnostic statement, Impaired physical mobility related to tibial fracture as
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evidenced by hospital client ’s inability to ambulate. Which part of the diagnostic sta
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t ement does the nursing attendant need to revise? a. Etiology
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b. Nursing diagnosis ra




c. Collaborative problem ra




d. Defining characteristic ra




ACCURATE ANSWER:-A ra



The etiology, or related to factor, of tibial fracture is a medical diagnosis and needs to be revi
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sed. The nursing diagnosis is appropriate because the hospital client is unable to ambulate.
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A collaborative problem is an actual or potential physiological complication that nursing att
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endant s monitor to detect the onset of changes in a hospital client ’s health status; there is n
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o collaborative problem listed. The defining characteristic (subjective and objective data that
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support the diagnosis) is appropriate for Impaired physical mobility.
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DIF:Apply (application) ra



OBJ:Compare a nursing diagnosis with a medical diagnosis and a collaborative problem.
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TOP:Diagnosis MSC: Management of Care ra ra ra




5. A nursing attendant is using assessment data gathered about a hospital client and co
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mbin
ing critical thinking to develop a nursing diagnosis. What phrase is used to identify
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what t he nursing attendant is doing? a. Assigning clinical cues
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b. Defining characteristics ra



c. Diagnostic reasoning ra




d. Diagnostic labeling ra




ACCURATE ANSWER:-C ra



Diagnostic reasoning is defined as a process of using the assessment data gathered about a
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hospital client to logically explain a clinical judgment, in this case a nursing diagnosis.
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Defining characteristics are assessment findings that support the nursing diagnosis. Definin
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g characteristics are the subjective and objective clinical cues, which a nursing attendant gat
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hers intentionally and unintentionally. The nursing attendant organizes all of the hospital cl
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ient ’s data into meaningful and usable data clusters, which lead to a diagnostic conclusion. Di
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agnostic labeling is simply the name of the diagnosis.
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, DIF:Understand (comprehension) ra



OBJ:Apply critical thinking in the diagnostic reasoning process. ra ra ra ra ra ra ra ar



TOP:Diagnosis MSC: Management of Care ra ra ra



6. A hospital client presents to the emergency department following a motor vehicle crash that
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causes a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the hospital c
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lient has no other major injuries, is in good health, and reports only moderate discomfort.
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Which is the most pertinent nursing diagnosis the nursing attendant will include in the pla
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n of care?
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a. Posttrauma syndrome ra




b. Constipation
c. Acute pain ra



d. Anxiety
ACCURATE ANSWER:-C ra



Based on the assessment data provided, the only supportive evidence for one of the diagnosis o
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ptions is ―Reports only moderate discomfort,‖ which would support Acute pain. No supporti
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ve evidence is provided for any of the other diagnoses. The hospital client may indeed develo
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p signs or symptoms of the other problems, but supportive data are presently lacking in the p
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rovided information. ra




DIF:Apply (application) ra



OBJ:Apply critical thinking in the diagnostic reasoning process. ra ra ra ra ra ra ra ar



TOP:Diagnosis MSC: Management of Care ra ra ra




7. The nursing attendant is reviewing a hospital client ’s database for significant changes and d
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iscovers that the hospital client has not voided in over 8 hours. The hospital client ’s kidney f
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unction lab results are abnormal, and the hospital client ’s oral intake has significantly decre
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ased since previous shifts. Which step of the nursing process should the nursing attendant p
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roceed to after this review? a. Diagnosis
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b. Planning
c. Implementation
d. Evaluation
ACCURATE ANSWER:-A ra



After a thorough assessment, the nursing attendant should proceed to analyzing the data and f
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ormulating a nursing diagnosis before proceeding with developing the plan of care and deter
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mining appropriate interventions; this is the diagnosis phase. The evaluation phase involves d
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etermining whether the goals were met, and interventions were effective. ra ra ra ra ra ra ra ra ra




DIF:Apply (application) ra



OBJ:Discuss the importance of having a standardized language of nursing diagnoses.
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TOP:Diagnosis MSC: Management of Care ra ra ra




8. A hospital client with a spinal cord injury is seeking to enhance urinary elimination abilities
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by learning selfcatheterization versus assisted catheterization by home health nursing attendant
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s and fami
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ly members. The nursing attendant adds Readiness for enhanced urinary elimination in the care pla
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n. Which type of diagnosis did the nursing attendant write?
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a. Risk
b. Problem focused ra




c. Health promotion ra




d. Collaborative problem ACCURATE ANSWER:-C ra ra