a
9. What information provides the nurse with accuracy when developing a nursing diagnosis?
A) A set of lab values
B) Abnormal diagnostic tests
C) A set of clinical cues
D) Specific nursing interventions
Ans: C
Feedback:
Each piece of client information is considered a clinical cue; a set of clinical cues forms a cluster that is present if the diagnosis is accurate.
6. What does the nursing diagnosis represent?
A) Symptoms
B) Signs
C) Cues
D) Maladaptation
Ans: C
Feedback:
Each nursing diagnosis represents a pattern of related client cues.
17. A nurse had identified several nursing diagnoses for a client. Which diagnosis
best reflects health promotion?
A) Constipation related to inadequate intake of fiber
B) Impaired skin integrity related to prolonged immobility
C) Readiness for enhanced family coping
D) Right hip fracture secondary to fall
Ans: C
Feedback:
The diagnosis of “readiness” reflects health promotion. The diagnoses about constipation and impaired skin integrity are actual nursing diagnoses. Right hip fracture is a medical diagnosis.
22. A nurse is preparing to write a nursing diagnosis for a client. Which activity would the nurse need to do first?
A) Identify the significant data
B) Cluster the cues
C) Synthesize cue clusters
D) Validate the diagnosis
Ans: A
Feedback:
The first step is to look at the data for cues. Significant data or cues will then be clustered. During cue clustering, critical thinking is used to analyze and synthesize the cues; that is, how they fit into a particular problem. The cues are then put together to form meaningful clusters that describe specific client problems. Cluster interpretation involves synthesizing the cue clusters; that is, to see the whole picture and attach meaning to the cluster. Once the nursing diagnosis is selected, it should be validated with the client.
25. A nurse is developing the plan of care for a client and establishes several nursing diagnoses based on assessment data. The nurse demonstrates an understanding of nursing diagnoses by focusing on which area?
A) Actions to be initiated for treatment
B) Human responses to actual or potential health problems
C) Pathophysiologic responses occurring in body systems
D) Problem validation through physician collaboration
Ans: B
Feedback:
The main focus of nursing diagnoses is on monitoring human responses to actual or potential health problems, whereas the main focus of medical diagnoses and collaborative problems is on monitoring the pathophysiologic responses of body organs or systems. Actions to be initiated for treatment are the main focus for interventions or treatment. Collaboration with the physician to validate the problem reflects medical diagnoses or collaborative problems.
21. Assessment of a client with difficulty breathing reveals thick, tenacious secretions in the trachea and bronchi and excessive sputum with coughing. The
respiratory rate is slightly increased. When developing this client’s plan of care,
which nursing diagnostic label would be most appropriate?
A) Risk for activity intolerance
B) Disturbed sleep pattern
C) Ineffective airway clearance
D) Impaired spontaneous ventilation
Ans: C
Feedback:
Based on the assessment, the nurse should identify specific cues, such as the thick secretions, excessive sputum, and coughing, which would indicate a problem with a clear airway. Although the client may be experiencing problems with his or her activity level or a disruption in his or her sleep from coughing, there is no indication that either of these is occurring. The client’s respiratory rate is increased; however, he or she is breathing independently.
12. The act of analyzing and synthesizing cues requires:
A) critical thinking.
B) certification.
C) advanced practice.
D) attendance at NANDA.
Ans: A
Feedback:
During clustering, critical thinking is used to analyze and synthesize cues.
10. One major requirement of a nursing diagnosis is that it focuses on a problem that is:
A) established by the physician.
B) based on the client’s pathophysiology.
C) legally treatable by registered nurses.
D) included within the diagnosis-related group.
Ans: C
Feedback:
Registered nurses are educated and licensed to make nursing diagnoses. As such, they have a duty to identify and plan care for clients based on them.
15. Why is coding important when writing a nursing diagnosis?
A) Enhances the professionalism of the nursing process
B) Allows for direct reimbursement for nurses
C) Evaluates the diagnostic statement for accuracy
D) Provides legal characteristics for licensure
Ans: B
Feedback:
Coding of nursing diagnoses in computerized systems allows direct reimbursement of nurses.
8. What is meant by impaired state of equilibrium?
A) It describes the client’s condition.
B) It is common terminology.
C) It is a nursing diagnosis.
D) It assists in planning care.
Ans: A
Feedback:
Descriptors such as "impaired state of equilibrium" describe changes in condition, state of the client, or some qualification of the specific nursing diagnosis.
2. The nursing diagnosis taxonomy provides nursing with:
A) legal information.
B) common language.
C) discharge planning.
D) evaluative care.
Ans: B
Feedback:
Professions require a sound scientific base; the nursing process is nursing’s scientific base. To achieve this scientific foundation, nursing requires a taxonomy, or classification system, to provide a structure for nursing practice.
16. What is the purpose of establishing a nursing diagnosis?
A) To describe a functional health problem
B) To collaborate with the physician
C) To identify medical problems
D) To meet accreditation criteria
Ans: A
Feedback:
Establishment of a nursing diagnosis reflects the synthesis of data gathered during a nursing assessment. Gordon suggested a framework for organizing nursing diagnoses based on functional health, thus offering a convenient way to cluster similar diagnoses.
20. A nurse is developing a plan of care for a client with a chronic respiratory problem. When developing appropriate nursing diagnoses for this client, the nurse needs to keep in mind that:
A) the interventions planned must be within the nurse’s scope of practice.
B) the problem’s existence requires validation by the physician.
C) the main focus is on monitoring the body’s pathophysiologic response.
D) The signs and symptoms of the disease are part of the information conveyed.
Ans: A
Feedback:
A nursing diagnosis describes an actual, risk, or wellness-human response to a health problem that nurses are responsible for treating independently. Nursing diagnoses describe the client’s response to the disease process, developmental stage, or life process and provide a convenient way to communicate nursing therapies or interventions. Nursing diagnoses carry legal ramifications. Only healthcare problems within the scope of nursing practice can be identified as nursing diagnoses. A nurse cannot diagnose a medical disease and is not licensed to independently treat such a problem. Although nurses may identify a problem,medical diagnoses require validation by the physician that the problem exists. The main focus of a medical diagnosis is on monitoring for pathophysiologic responses of body organs and systems. Medical diagnoses convey information about signs and symptoms of disease and provide a convenient means for communicating treatment requirements.
1. What is the nurse accountable for, according to state nurse practice acts?
A) Managing the care team effectively
B) Making nursing diagnoses
C) Prescribing PRN (as needed) medications
D) Mentoring other nurses
Ans: B
Feedback:
State nurse practice acts have included diagnosis as part of the domain of nursing practice for which nurses are held accountable. Overall management of the care team is not an explicit responsibility of nurses. Nurses generally do not have prescriptive authority. The responsibility for mentorship is not enacted in law.
18. Which assessment finding would support the nursing diagnosis of acute pain?
Select all that apply.
A) The client had an abdominal hysterectomy 1 day ago.
B) The client is crying in pain about 20 minutes before his or her pain medicine is due.
C) The client has a history of osteoarthritis.
D) The client had back surgery 2 years ago and expresses the need for ibuprofen on most days.
E) The client is a heavy cigarette smoker.
Ans: A, B
Feedback:
The client crying in pain 1 day after surgery would be expected and lead to a nursing diagnosis of acute pain. Although the client likely experiences pain from the past back surgery and osteoarthritis, it would not support the diagnosis of acute pain. The smoking history does not support the diagnosis.
19. The following nursing diagnosis appears on a clients plan of care: Impaired Physical Mobility related to postoperative pain as evidenced by difficulty ambulating. The nurse identifies the descriptor in this nursing diagnosis as:
A) impaired.
B) physical mobility.
C) postoperative pain.
D) difficulty ambulating.
Ans: A
Feedback:
Descriptors are words used to give additional meaning to a nursing diagnosis. They describe the change in condition, state of the client, or some qualification of the specific nursing diagnosis. The word "impaired" is a descriptor. Physical mobility is
4. Nursing diagnoses that require physician-prescribed and nurse-prescribed actions would be what type of problems?
A) Independent health problems
B) Collaborative health problems
C) Physician-developed problems
D) Interdisciplinary health problems
Ans: B
Feedback:
If problems require physician-prescribed and nurse-prescribed actions, they are collaborative health problems.
14. Which statement appropriately identifies a nursing diagnosis reflecting vulnerability of a woman 78 years of age who is confined to bed?
A) Ineffective airway clearance related to bed rest
B) Immobility related to confinement to bed
C) Potential for pneumonia related to inactivity
D) Risk for impaired skin integrity related to bed rest
Ans: D
Feedback:
An at-risk nursing diagnosis, as defined by NANDA, "describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community."
23. A nurse has identified a risk nursing diagnosis for a client. When writing this diagnosis, the nurse would write a statement consisting of how many parts?
A) One
B) Two
C) Three
D) Four
Ans: B
Feedback:
A risk nursing diagnosis is a two-part statement consisting of a diagnostic label and risk factors. It does not include defining characteristics. Health promotion diagnoses are one-part statements that include only the diagnostic label. An actual nursing diagnosis is a three-part statement that includes a diagnostic label, defining characteristics, and related factors.
13. A nurse sees the client grimace and documents that the client is in pain, without interviewing the client to obtain further cues. The nurse has:
A) impaired cluster interpretation.
B) a lack of cues, or premature closure.
C) ineffective database.
D) inaccurate evaluation.
Ans: B
Feedback:
The lack of adequate cues is called premature closure.
7. What gives additional meaning to a nursing diagnosis?
A) Composition
B) Descriptors
C) Dysfunction
D) Qualifications
Ans: B
Feedback:
Descriptors are words used to give additional meaning to a nursing diagnosis.
24. A client has significant problems related to breathing for which the nurse identifies several nursing diagnostic labels, including ineffective breathing pattern and impaired gas exchange. The nurse understands that these diagnostic labels are based on which organizing framework?
A) Functional health patterns
B) Body system affected
C) Maslow’s hierarchy
D) Reimbursement codes
Ans: A
Feedback:
Nursing diagnoses are based on a functional health pattern assessment framework, not body system affected, Maslow’s hierarchy, or reimbursement codes.
5. In the development of a nursing diagnosis for a client who has cachexia and decreased weight, what would be an appropriate nursing diagnosis?
A) Anorexia nervosa and bulimia
B) Lack of adequate nutrition related to decreased calories
C) Weight loss related to abdominal discomfort
D) Imbalanced nutrition: less than body requirements
Ans: D
Feedback:
Another common mistake is to write "lack of adequate nutrition" as the nursing diagnosis. The most appropriate nursing diagnosis would be imbalanced nutrition: less than body requirements.
11. A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues provide organization, or:
A) categorizing.
B) diagnosing.
C) grouping.
D) clustering.
Ans: D
Feedback:
Cue clustering brings together cues that if viewed separately would not convey the same meaning.
3. Which of the following is classified as a nursing diagnosis?
A) Esophageal cancer
B) Cholecystitis
C) Grieving
D) Pneumonia
Ans: C
Feedback:
Grieving is a nursing diagnosis per the latest NANDA Taxonomy. The other choices are medical diagnoses.