nursing diagnosis UPDATED ACTUAL Questions and CORRECT
Answers
A nurse's assessment reveals a patient having frequent 2
voiding and pain when she urinates. Her body
temperature is 38°C (100.4°F). The nurse asks whether she
has to go to the bathroom at night, and the patient
responds, "Yes." When asked how often, the patient
replies, "About three times a night." The nurse asks if
having to urinate at night is recent or normal for the
patient. The patient explains, "I usually go once a night
but that is all." The nurse then asks, "When you feel the
need to go, can you reach the toilet in time?" The patient
says, "Oh, yes, I can." The nurse asks, "And have you had
any leaking of urine?" The patient denies leaking. When
asked if she is having any back or abdominal pain, the
patient denies discomfort. The nurse then gathers a urine
specimen from the patient and inspects its character,
noting it is cloudy and foul smelling. Which of the
following nursing diagnoses are indicated by cues in this
patient's assessment?
1. Impaired Kidney Function
2. Impaired Urination
3. Urge Incontinence of Urine
4. Total Urinary Incontinence
, A nursing student is working with a faculty member to 2
identify a nursing diagnosis for an assigned patient. The
student has assessed that the patient is undergoing
radiation treatment to the abdomen, has liquid stool, and
the skin is clean and intact. The student selects the
nursing diagnosis Impaired Skin Integrity. The faculty
member explains that the student has made a diagnostic
error for which of the following reasons?
1. Incorrect clustering of data
2. Wrong diagnosis
3. Condition is a collaborative problem
4. Premature ending assessment
A nurse assesses a 42-year-old woman at a health clinic. 2,4,7
The woman is married and lives in a condo with her
husband. She reports having frequent voiding and pain
when she urinates. The nurse asks whether she has to go
to the bathroom at night, and the patient responds, "Yes,
usually twice or more." The patient had an episode of
diarrhea 1 week ago. She weighs 136 kg (300 lb) and
reports having difficulty cleansing herself after voiding or
passing stool. Which of the following demonstrate
assessment findings that cluster to indicate the nursing
diagnosis Impaired Urination. (Select all that apply.)
1. Age 42
2. Dysuria
3. Difficulty performing perineal hygiene
4. Nocturia
5. Episode of diarrhea
6. Weighs 136 kg (300 lb)
7. Frequent voiding
Review the following nursing diagnoses and identify the 2,4
diagnoses that are stated correctly. (Select all that apply.)
1. Offer frequent skin care because of Impaired Skin
Integrity
2. Risk for Infection
3. Chronic Pain related to osteoarthritis evidenced by
reduced hip range of motion
4. Activity Intolerance related to physical deconditioning
evidenced by exertional dyspnea
5. Lack of Knowledge related to laser surgery
A home health nurse completes a home safety risk for fall
assessment. The data reveal that the patient is 71 years old
with bilateral cataracts that are causing blurred vision and
sensitivity to bright lights. The patient is recovering from a
stroke that has caused left-sided weakness of the leg,
with an unsteady gait. When talking with the patient, the
nurse learns the patient lives alone and fell in the
bathroom 4 months ago. Rooms in the home are in
disrepair. The nurse identifies nursing diagnoses of
Impaired Vision, Impaired Mobility, and Risk for Fall.
Which diagnosis is the nurse's priority? Give a rationale.
Answers
A nurse's assessment reveals a patient having frequent 2
voiding and pain when she urinates. Her body
temperature is 38°C (100.4°F). The nurse asks whether she
has to go to the bathroom at night, and the patient
responds, "Yes." When asked how often, the patient
replies, "About three times a night." The nurse asks if
having to urinate at night is recent or normal for the
patient. The patient explains, "I usually go once a night
but that is all." The nurse then asks, "When you feel the
need to go, can you reach the toilet in time?" The patient
says, "Oh, yes, I can." The nurse asks, "And have you had
any leaking of urine?" The patient denies leaking. When
asked if she is having any back or abdominal pain, the
patient denies discomfort. The nurse then gathers a urine
specimen from the patient and inspects its character,
noting it is cloudy and foul smelling. Which of the
following nursing diagnoses are indicated by cues in this
patient's assessment?
1. Impaired Kidney Function
2. Impaired Urination
3. Urge Incontinence of Urine
4. Total Urinary Incontinence
, A nursing student is working with a faculty member to 2
identify a nursing diagnosis for an assigned patient. The
student has assessed that the patient is undergoing
radiation treatment to the abdomen, has liquid stool, and
the skin is clean and intact. The student selects the
nursing diagnosis Impaired Skin Integrity. The faculty
member explains that the student has made a diagnostic
error for which of the following reasons?
1. Incorrect clustering of data
2. Wrong diagnosis
3. Condition is a collaborative problem
4. Premature ending assessment
A nurse assesses a 42-year-old woman at a health clinic. 2,4,7
The woman is married and lives in a condo with her
husband. She reports having frequent voiding and pain
when she urinates. The nurse asks whether she has to go
to the bathroom at night, and the patient responds, "Yes,
usually twice or more." The patient had an episode of
diarrhea 1 week ago. She weighs 136 kg (300 lb) and
reports having difficulty cleansing herself after voiding or
passing stool. Which of the following demonstrate
assessment findings that cluster to indicate the nursing
diagnosis Impaired Urination. (Select all that apply.)
1. Age 42
2. Dysuria
3. Difficulty performing perineal hygiene
4. Nocturia
5. Episode of diarrhea
6. Weighs 136 kg (300 lb)
7. Frequent voiding
Review the following nursing diagnoses and identify the 2,4
diagnoses that are stated correctly. (Select all that apply.)
1. Offer frequent skin care because of Impaired Skin
Integrity
2. Risk for Infection
3. Chronic Pain related to osteoarthritis evidenced by
reduced hip range of motion
4. Activity Intolerance related to physical deconditioning
evidenced by exertional dyspnea
5. Lack of Knowledge related to laser surgery
A home health nurse completes a home safety risk for fall
assessment. The data reveal that the patient is 71 years old
with bilateral cataracts that are causing blurred vision and
sensitivity to bright lights. The patient is recovering from a
stroke that has caused left-sided weakness of the leg,
with an unsteady gait. When talking with the patient, the
nurse learns the patient lives alone and fell in the
bathroom 4 months ago. Rooms in the home are in
disrepair. The nurse identifies nursing diagnoses of
Impaired Vision, Impaired Mobility, and Risk for Fall.
Which diagnosis is the nurse's priority? Give a rationale.
