Question 1

The process of using assessment data gathered about a patient combined with critical thinking to explain a nursing diagnosis is known as

Accepted Answer

A)  Diagnostic reasoning. 
B)  Defining characteristics. 
C)  Assigning clinical criteria. 
D)  Diagnostic labeling. 
A)  Diagnostic reasoning. 
B)  Defining characteristics. 
C)  Assigning clinical criteria. 
D)  Diagnostic labeling. A

Question 2

Which nursing diagnostic statement is accurately written for a patient with a medical diagnosis of pneumonia?

Accepted Answer

A)  Risk for infection related to lower lobe infiltrate 
B)  Risk for deficient fluid volume related to dehydration 
C)  Impaired gas exchange related to alveolar-capillary membrane changes 
D)  Ineffective breathing pattern related to pneumonia 
A)  Risk for infection related to lower lobe infiltrate 
B)  Risk for deficient fluid volume related to dehydration 
C)  Impaired gas exchange related to alveolar-capillary membrane changes 
D)  Ineffective breathing pattern related to pneumonia C

Question 3

A new graduate nurse is not sure what the heart sound is that she is listening to on a patient.To avoid diagnostic error,what should the nurse do?

Accepted Answer

A)  Assign the nursing diagnosis of Decreased cardiac output. 
B)  Ask the patient if he has a history of cardiac problems before assigning the diagnosis of Decisional conflict. 
C)  Check the previous shift's assessment and document what was noted on the last shift. 
D)  Ask a more experienced nurse to listen also. 
A)  Assign the nursing diagnosis of Decreased cardiac output. 
B)  Ask the patient if he has a history of cardiac problems before assigning the diagnosis of Decisional conflict. 
C)  Check the previous shift's assessment and document what was noted on the last shift. 
D)  Ask a more experienced nurse to listen also. D

Question 4

Identify the defining characteristics in the nursing diagnosis statement: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days,abdominal distention,and complaints of abdominal pain.

Accepted Answer

A)  Decreased gastrointestinal motility 
B)  Pain medication 
C)  Abdominal distention 
D)  Constipation 
A)  Decreased gastrointestinal motility 
B)  Pain medication 
C)  Abdominal distention 
D)  Constipation

Question 5

The nurse is reviewing a patient's database for significant changes and discovers that the patient has not voided in over 8 hours.The patient's kidney function labs are abnormal,and the patient's oral intake has significantly decreased since previous shifts.Which step of the nursing process should the nurse proceed to after this review?

Accepted Answer

A)  Diagnosis 
B)  Planning 
C)  Implementation 
D)  Evaluation 
A)  Diagnosis 
B)  Planning 
C)  Implementation 
D)  Evaluation

Question 6

A nurse assesses that a patient has not voided in 6 hours.Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention?

Accepted Answer

A)  "Do you feel like you need to use the bathroom?" 
B)  "Are you able to walk to the bathroom by yourself?" 
C)  "When was the last time you took your medicine?" 
D)  "Do you have a safety rail in your bathroom at home?" 
A)  "Do you feel like you need to use the bathroom?" 
B)  "Are you able to walk to the bathroom by yourself?" 
C)  "When was the last time you took your medicine?" 
D)  "Do you have a safety rail in your bathroom at home?"

Question 7

A patient with a spinal cord injury is seeking to enhance his urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members.The nursing diagnosis Readiness for enhanced urinary elimination is which type of diagnosis?

Accepted Answer

A)  Actual 
B)  Risk 
C)  Health promotion 
D)  Wellness 
A)  Actual 
B)  Risk 
C)  Health promotion 
D)  Wellness

Question 8

The patient database reveals that a patient has decreased oral intake,decreased oxygen saturation when ambulating,complaints of shortness of breath when getting out of bed,and a productive cough.What are the defining characteristics for the diagnostic label of Activity intolerance?

Accepted Answer

A)  Decreased oral intake and decreased oxygen saturation when ambulating 
B)  Decreased oxygen saturation when ambulating and complaints of shortness of breath when getting out of bed 
C)  Complaints of shortness of breath when getting out of bed and a productive cough 
D)  Productive cough and decreased oral intake 
A)  Decreased oral intake and decreased oxygen saturation when ambulating 
B)  Decreased oxygen saturation when ambulating and complaints of shortness of breath when getting out of bed 
C)  Complaints of shortness of breath when getting out of bed and a productive cough 
D)  Productive cough and decreased oral intake

Question 9

Which diagnosis below is NANDA-I approved?

Accepted Answer

A)  Sleep disorder 
B)  Acute pain 
C)  Sore throat 
D)  High blood pressure 
A)  Sleep disorder 
B)  Acute pain 
C)  Sore throat 
D)  High blood pressure

Question 10

Which of these findings,when evaluating another nurse developing a plan of care,should the charge nurse recognize as a source of diagnostic error?

Accepted Answer

A)  Assigning diagnoses while completing the database 
B)  Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous antibiotics 
C)  Completing the interview before performing the physical examination 
D)  Documenting cultural and religious preferences 
A)  Assigning diagnoses while completing the database 
B)  Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous antibiotics 
C)  Completing the interview before performing the physical examination 
D)  Documenting cultural and religious preferences

Question 11

A patient exhibits the following symptoms: tachycardia,increased thirst,headache,decreased urine output,and increased body temperature.After analyzing these data,the nurse assigns which of the following nursing diagnoses?

Accepted Answer

A)  Adult failure to thrive 
B)  Hypothermia 
C)  Deficient fluid volume 
D)  Nausea 
A)  Adult failure to thrive 
B)  Hypothermia 
C)  Deficient fluid volume 
D)  Nausea

Question 12

A patient of Middle Eastern descent has lost 5 lbs during hospitalization and states that the food offered is not allowed in his diet owing to religious preferences.Based on this information,an appropriate nursing diagnostic statement is Imbalanced nutrition: less than body requirements related to

Accepted Answer

A)  Religious preferences. 
B)  Decreased oral intake. 
C)  Weight loss. 
D)  Race and ethnicity. 
A)  Religious preferences. 
B)  Decreased oral intake. 
C)  Weight loss. 
D)  Race and ethnicity.

Question 13

Which of these questions would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea?

Accepted Answer

A)  "What types of foods do you think caused your upset stomach?" 
B)  "How many bowel movements a day have you had?" 
C)  "Are you able to get to the bathroom in time?" 
D)  "What medications are you currently taking?" 
A)  "What types of foods do you think caused your upset stomach?" 
B)  "How many bowel movements a day have you had?" 
C)  "Are you able to get to the bathroom in time?" 
D)  "What medications are you currently taking?"

Question 14

A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900.The nursing assistant then reports to the nurse that the patient's blood pressure was low when it was taken at 0830.The nursing assistant states she was busy and had not had a chance to tell the nurse yet.The patient begins to complain of feeling dizzy and light-headed.The blood pressure is re-checked and it has dropped even lower.The nurse first made an error in what phase of the nursing process?

Accepted Answer

A)  Assessment 
B)  Diagnosis 
C)  Planning 
D)  Evaluation 
A)  Assessment 
B)  Diagnosis 
C)  Planning 
D)  Evaluation

Question 15

One purpose of using standard formal nursing diagnoses in practice is to

Accepted Answer

A)  Form a language that can be encoded only by nurses. 
B)  Distinguish the nurse's role from the physician's role. 
C)  Allow for the communication of patient needs to assistive personnel. 
D)  Help nurses focus on the scope of medical practice. 
A)  Form a language that can be encoded only by nurses. 
B)  Distinguish the nurse's role from the physician's role. 
C)  Allow for the communication of patient needs to assistive personnel. 
D)  Help nurses focus on the scope of medical practice.

Question 16

After completing a thorough assessment to formulate a patient database,the nurse should proceed to which step of the nursing process?

Accepted Answer

A)  Diagnosis 
B)  Planning 
C)  Implementation 
D)  Evaluation 
A)  Diagnosis 
B)  Planning 
C)  Implementation 
D)  Evaluation

Question 17

Which of these selections is an etiology for Acute pain versus a defining characteristic?

Accepted Answer

A)  Complaint of pain as a 7 on a 0 to 10 scale 
B)  Disruption of tissue integrity 
C)  Dull headache 
D)  Discomfort while changing position 
A)  Complaint of pain as a 7 on a 0 to 10 scale 
B)  Disruption of tissue integrity 
C)  Dull headache 
D)  Discomfort while changing position

Question 18

A patient presents to the emergency department following a motor vehicle crash and suffers from a right femur fracture.The leg is stabilized in a full leg cast.Otherwise,the patient has no other major injuries,is in good health,and complains only of moderate discomfort.What is the most pertinent nursing diagnosis to be included in the plan of care based on the assessment data provided?

Accepted Answer

A)  Posttrauma syndrome 
B)  Constipation 
C)  Urinary retention 
D)  Acute pain 
A)  Posttrauma syndrome 
B)  Constipation 
C)  Urinary retention 
D)  Acute pain

Question 19

The charge 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 to bathroom.The nurse needs to revise which part of the diagnostic statement?

Accepted Answer

A)  Nursing diagnosis 
B)  Etiology 
C)  Patient chief complaint 
D)  Defining characteristic 
A)  Nursing diagnosis 
B)  Etiology 
C)  Patient chief complaint 
D)  Defining characteristic

Exam 17: Nursing Diagnosis

The process of using assessment data gathered about a patient combined with critical thinking to explain a nursing diagnosis is known as

Which nursing diagnostic statement is accurately written for a patient with a medical diagnosis of pneumonia?

A new graduate nurse is not sure what the heart sound is that she is listening to on a patient.To avoid diagnostic error,what should the nurse do?

A nurse assesses that a patient has not voided in 6 hours.Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention?

A patient with a spinal cord injury is seeking to enhance his urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members.The nursing diagnosis Readiness for enhanced urinary elimination is which type of diagnosis?

The patient database reveals that a patient has decreased oral intake,decreased oxygen saturation when ambulating,complaints of shortness of breath when getting out of bed,and a productive cough.What are the defining characteristics for the diagnostic label of Activity intolerance?

Which diagnosis below is NANDA-I approved?

Which of these findings,when evaluating another nurse developing a plan of care,should the charge nurse recognize as a source of diagnostic error?

A patient exhibits the following symptoms: tachycardia,increased thirst,headache,decreased urine output,and increased body temperature.After analyzing these data,the nurse assigns which of the following nursing diagnoses?

A patient of Middle Eastern descent has lost 5 lbs during hospitalization and states that the food offered is not allowed in his diet owing to religious preferences.Based on this information,an appropriate nursing diagnostic statement is Imbalanced nutrition: less than body requirements related to

Which of these questions would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea?

One purpose of using standard formal nursing diagnoses in practice is to

After completing a thorough assessment to formulate a patient database,the nurse should proceed to which step of the nursing process?

Which of these selections is an etiology for Acute pain versus a defining characteristic?

The charge 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 to bathroom.The nurse needs to revise which part of the diagnostic statement?

Nursing Today

The Health Care Delivery System

Community-Based Nursing Practice

Theoretical Foundations of Nursing Practice

Evidence-Based Practice

Health and Wellness

Caring in Nursing Practice

Caring for the Cancer Survivor

Culture and Ethnicity

Caring for Families

Developmental Theories

Conception Through Adolescence

Young and Middle Adults

Older Adults

Critical Thinking in Nursing Practice

Nursing Assessment

Planning Nursing Care

Implementing Nursing Care

Evaluation

Managing Patient Care

Ethics and Values

Legal Implications in Nursing Practice

Communication

Patient Education

Documentation and Informatics

Patient Safety

Infection Prevention and Control

Vital Signs

Health Assessment and Physical Examination

Medication Administration

Complementary and Alternative Therapies

Self-Concept

Sexuality

Spiritual Health

The Experience of Loss, death, and Grief

Stress and Coping

Activity and Exercise

Hygiene

Oxygenation

Fluid, electrolyte, and Acid-Base Balance

Sleep

Pain Management

Nutrition

Urinary Elimination

Bowel Elimination

Mobility and Immobility

Skin Integrity and Wound Care

Sensory Alterations

Care of Surgical Patients

Filters