CHAPTER 17 NURSING DIAGNOSIS STUDY
GUIDE QUESTIONS AND SOLUTIONS
◉ Following an assessment, the nurse is formulating a nursing diagnosis
using the PES format. What does the "P" in the acronym PES stand for?
1
Period
2
Problem
3
Prevention
4
Predication. Answer: 2 Problem-PES format is a nursing diagnosis in
three parts. It includes diagnostic label, etiological statement, and
symptoms or defining characteristics. The "P" stands for problem, the
"E" stands for etiology or related factor, and the "S" stands for
symptoms or defining characteristics. The "P" does not stand for period,
prevention, or predication.
Test-Taking Tip: Tell yourself, "It will be a PROBLEM on the test if I
forget what the P of PES means." The P of PES stands for problem!
Text Reference - p. 230
◉ Which patient-related factors fall under health promotion nursing
diagnosis? Select all that apply.
A
The patient follows poor hygiene measures.
B
The patient is willing to consume nutritious foods.
C
The patient shows impaired interaction with society.
D
The patient is ready to enhance his or her coping skills.
E
The patient shows readiness to perform regular exercises.. Answer: B-
The patient is willing to consume nutritious foods
,D-The patient is ready to enhance his or her coping skills
E-The patient shows readiness to perform regular exercises.
Health promotion nursing diagnosis is a clinical judgment of a patient's
motivation, desire, and readiness to increase well-being. While
performing health promotion nursing diagnoses, the nurse should focus
on the patient's readiness to eat nutritious food. While performing
health promotion nursing diagnosis, the nurse should assess the patient's
readiness to enhance coping skills and to perform regular exercise. While
performing risk nursing diagnosis, the nurse should focus on poor
hygiene measures of the patient. While performing actual nursing
diagnosis, the nurse should focus on the patient's social interaction
ability.
Text Reference - p. 228
◉ The nurse completed the following assessment: 63-year-old female
client has had abdominal pain for 6 days. She reports not having a bowel
movement for 4 days, whereas she normally has a bowel movement
every 2 to 3 days. She has not been hospitalized in the past. Her
abdomen is distended. She reports being anxious about upcoming tests.
Her temperature was 37° C, pulse 82 and regular, blood pressure
128/72. Which of the following data form a cluster, showing a relevant
pattern? Select all that apply.
1
Vital sign results
2
Abdominal distention
3
Age of client
4
Change in bowel elimination pattern
5
Abdominal pain
6
No past history of hospitalization. Answer: 2-Abdominal distention
4-Change In bowel elimination pattern
5-Abdominal pain
The presence of abdominal pain, distention, and a change in bowel
elimination pattern forms a cluster , suggesting an elimination problem.
, Text Reference - p. 226
◉ What could be the effect of an incorrect nursing diagnosis?
1
It could affect the quality of client care.
2
It would get corrected automatically in the system.
3
It could affect the client's cost of treatment.
4
It could produce a psychological disorder in the client. Answer: 1-It
could affect the quality of client care.
An incorrect nursing diagnosis may affect the quality of client care.
Incorrect nursing diagnoses are not corrected automatically in the
system. The cost of the client's care is not dependent on the nursing
diagnosis. An incorrect nursing diagnosis would not create a
psychological disorder in the client.
Text Reference - p. 232
◉ Which finding would indicate acute pain in a patient?
1
The patient has dilated pupils.
2
The patient has absence of fatigue signs.
3
The patient does not show fear of reinjury.
4
The patient does not show signs of depression. Answer: 1-The patient
has dilated pupils
Pupil dilation is a characteristic of acute pain. Therefore, if the patient
has dilated pupils, it supports the nurse's conclusion. The defining
characteristics for chronic pain are signs of fatigue, fear of reinjury, and
depression. The patient does not show these signs; therefore, the patient
does not have chronic pain.
Text Reference - p. 227
◉ Which nursing intervention is most beneficial to a patient who has
impaired mobility due to a musculoskeletal injury in both legs?
GUIDE QUESTIONS AND SOLUTIONS
◉ Following an assessment, the nurse is formulating a nursing diagnosis
using the PES format. What does the "P" in the acronym PES stand for?
1
Period
2
Problem
3
Prevention
4
Predication. Answer: 2 Problem-PES format is a nursing diagnosis in
three parts. It includes diagnostic label, etiological statement, and
symptoms or defining characteristics. The "P" stands for problem, the
"E" stands for etiology or related factor, and the "S" stands for
symptoms or defining characteristics. The "P" does not stand for period,
prevention, or predication.
Test-Taking Tip: Tell yourself, "It will be a PROBLEM on the test if I
forget what the P of PES means." The P of PES stands for problem!
Text Reference - p. 230
◉ Which patient-related factors fall under health promotion nursing
diagnosis? Select all that apply.
A
The patient follows poor hygiene measures.
B
The patient is willing to consume nutritious foods.
C
The patient shows impaired interaction with society.
D
The patient is ready to enhance his or her coping skills.
E
The patient shows readiness to perform regular exercises.. Answer: B-
The patient is willing to consume nutritious foods
,D-The patient is ready to enhance his or her coping skills
E-The patient shows readiness to perform regular exercises.
Health promotion nursing diagnosis is a clinical judgment of a patient's
motivation, desire, and readiness to increase well-being. While
performing health promotion nursing diagnoses, the nurse should focus
on the patient's readiness to eat nutritious food. While performing
health promotion nursing diagnosis, the nurse should assess the patient's
readiness to enhance coping skills and to perform regular exercise. While
performing risk nursing diagnosis, the nurse should focus on poor
hygiene measures of the patient. While performing actual nursing
diagnosis, the nurse should focus on the patient's social interaction
ability.
Text Reference - p. 228
◉ The nurse completed the following assessment: 63-year-old female
client has had abdominal pain for 6 days. She reports not having a bowel
movement for 4 days, whereas she normally has a bowel movement
every 2 to 3 days. She has not been hospitalized in the past. Her
abdomen is distended. She reports being anxious about upcoming tests.
Her temperature was 37° C, pulse 82 and regular, blood pressure
128/72. Which of the following data form a cluster, showing a relevant
pattern? Select all that apply.
1
Vital sign results
2
Abdominal distention
3
Age of client
4
Change in bowel elimination pattern
5
Abdominal pain
6
No past history of hospitalization. Answer: 2-Abdominal distention
4-Change In bowel elimination pattern
5-Abdominal pain
The presence of abdominal pain, distention, and a change in bowel
elimination pattern forms a cluster , suggesting an elimination problem.
, Text Reference - p. 226
◉ What could be the effect of an incorrect nursing diagnosis?
1
It could affect the quality of client care.
2
It would get corrected automatically in the system.
3
It could affect the client's cost of treatment.
4
It could produce a psychological disorder in the client. Answer: 1-It
could affect the quality of client care.
An incorrect nursing diagnosis may affect the quality of client care.
Incorrect nursing diagnoses are not corrected automatically in the
system. The cost of the client's care is not dependent on the nursing
diagnosis. An incorrect nursing diagnosis would not create a
psychological disorder in the client.
Text Reference - p. 232
◉ Which finding would indicate acute pain in a patient?
1
The patient has dilated pupils.
2
The patient has absence of fatigue signs.
3
The patient does not show fear of reinjury.
4
The patient does not show signs of depression. Answer: 1-The patient
has dilated pupils
Pupil dilation is a characteristic of acute pain. Therefore, if the patient
has dilated pupils, it supports the nurse's conclusion. The defining
characteristics for chronic pain are signs of fatigue, fear of reinjury, and
depression. The patient does not show these signs; therefore, the patient
does not have chronic pain.
Text Reference - p. 227
◉ Which nursing intervention is most beneficial to a patient who has
impaired mobility due to a musculoskeletal injury in both legs?
