nclex questions chapter 14 diagnosing
1. A registered nurse is writing a diagnosis for a patient who is in traction because of
multiple fractures from a motor vehicle accident. Which nursing actions are related to
this step in the nursing process? Select all that apply.
a. The nurse uses the nursing interview to collect patient data.
b. The nurse analyzes data collected in the nursing assessment.
c. The nurse develops a care plan for the patient.
d. The nurse points out the patient's strengths.
e. The nurse assesses the patient's mental status.
f. The nurse identifies community resources to help his family cope. correct answers b,
d, f. The purposes of diagnosing are to identify how an individual, group, or community
responds to actual or potential health and life processes; identify factors that contribute
to or cause health problems (etiologies); and identify resources or strengths the
individual, group, or community can draw on to prevent or resolve problems. In the
diagnosing step of the nursing process, the nurse interprets and analyzes data gathered
from the nursing assessment, identifies patient strengths, and identifies resources the
patient can use to resolve problems. The nurse assesses and collects patient data in
the assessment step and develops a care plan in the planning step of the nursing
process.
2. A nurse is caring for a patient who presents with labored respirations, productive
cough, and fever. What would be appropriate nursing diagnoses for this patient? Select
all that apply.
a. Bronchial pneumonia
b. Impaired gas exchange
c. Ineffective airway clearance
d. Potential complication: sepsis
e. Infection related to pneumonia
f. Risk for septic shock correct answers b, c, f. Nursing diagnoses are actual or
potential health problems that can be prevented or resolved by independent nursing
interventions, such as impaired gas exchange, ineffective airway clearance, or risk for
septic shock. Bronchial pneumonia and infection are medical diagnoses, and "potential
complication: sepsis" is a collaborative problem.
3. After assessing a patient who is recovering from a stroke in a rehabilitation facility, a
nurse interprets and analyzes the patient data. Which of the four basic conclusions has
the nurse reached when identifying the need to collect more data to confirm a diagnosis
of situational low self-esteem?
a. No problem
b. Possible problem
c. Actual nursing diagnosis
1. A registered nurse is writing a diagnosis for a patient who is in traction because of
multiple fractures from a motor vehicle accident. Which nursing actions are related to
this step in the nursing process? Select all that apply.
a. The nurse uses the nursing interview to collect patient data.
b. The nurse analyzes data collected in the nursing assessment.
c. The nurse develops a care plan for the patient.
d. The nurse points out the patient's strengths.
e. The nurse assesses the patient's mental status.
f. The nurse identifies community resources to help his family cope. correct answers b,
d, f. The purposes of diagnosing are to identify how an individual, group, or community
responds to actual or potential health and life processes; identify factors that contribute
to or cause health problems (etiologies); and identify resources or strengths the
individual, group, or community can draw on to prevent or resolve problems. In the
diagnosing step of the nursing process, the nurse interprets and analyzes data gathered
from the nursing assessment, identifies patient strengths, and identifies resources the
patient can use to resolve problems. The nurse assesses and collects patient data in
the assessment step and develops a care plan in the planning step of the nursing
process.
2. A nurse is caring for a patient who presents with labored respirations, productive
cough, and fever. What would be appropriate nursing diagnoses for this patient? Select
all that apply.
a. Bronchial pneumonia
b. Impaired gas exchange
c. Ineffective airway clearance
d. Potential complication: sepsis
e. Infection related to pneumonia
f. Risk for septic shock correct answers b, c, f. Nursing diagnoses are actual or
potential health problems that can be prevented or resolved by independent nursing
interventions, such as impaired gas exchange, ineffective airway clearance, or risk for
septic shock. Bronchial pneumonia and infection are medical diagnoses, and "potential
complication: sepsis" is a collaborative problem.
3. After assessing a patient who is recovering from a stroke in a rehabilitation facility, a
nurse interprets and analyzes the patient data. Which of the four basic conclusions has
the nurse reached when identifying the need to collect more data to confirm a diagnosis
of situational low self-esteem?
a. No problem
b. Possible problem
c. Actual nursing diagnosis
