Ch. 5 Practice questions

A nurse has collecting extensive data during a client assessment and is performing the first step in the process of data analysis. Successful completion of this step requires the nurse to do which of the following? A) Differentiate between expected findings and abnormal findings. B) Validate nursing diagnoses with the client and the client's family. C) Integrate the client's medical diagnosis with nursing diagnoses. D) Perform health promotion education.

A) Differentiate between expected findings and abnormal findings.

A nurse has completed a client's initial assessment and is preparing to identify abnormal data and the client's strengths. Successful completion of this phase of the nursing process most requires which of the following? A) Knowledge of anatomy and physiology B) Awareness of the client's medical prognosis C) Inferences about the client D) Knowledge about the referral process

A) Knowledge of anatomy and physiology

A nurse has admitted a client to the medical unit who has just been diagnosed with endocarditis secondary to IV drug use. The nurse has completed the collection of objective and subjective data. What question should guide the next step in the nurse's data analysis? A) "What are this client's strengths?" B) "What is this client's prognosis?" C) "Why does this client use opioids?" D) "What are this client's hopes for the future?"

A) "What are this client's strengths?"

A nurse is providing care for a client who has longstanding type 2 diabetes. In recent days, the client's blood glucose levels have been higher and more volatile than usual. After drawing this inference, the nurse should take what action? A) Make appropriate referrals B) Assess the client more frequently C) Document the medical diagnosis of hyperglycemia D) Beginning collecting subjective data

A) Make appropriate referrals

The emergency department has collected extensive data from a client who has presented with a new onset of severe abdominal pain. What nursing action should the nurse perform before proceeding with data analysis? A) Validate the collected data. B) Formulate a nursing diagnosis. C) Make inferences about the data. D) Identify the client's strengths.

A) Validate the collected data.

A nurse is determining whether the data for a client support a potential nursing diagnosis. The nurse is most likely engaged in which step in the diagnostic reasoning process? A) Step Three: Draw Inferences B) Step Four: Propose Possible Nursing Diagnoses C) Step Five: Check for Defining Characteristics D) Step Six: Confirm or Rule Out Diagnoses

D) Step Six: Confirm or Rule Out Diagnoses

A nurse on a busy acute medical unit asks a clinical educator for suggestions on how to best develop expertise in using diagnostic reasoning skills to arrive at correct conclusions. Which of the following statements would be most appropriate? A) "You need to cluster the data more rapidly." B) "This skill comes with accumulating experience." C) "Try to be more efficient in documenting the data." D) "This is a skill that only comes with an advanced practice designation."

B) "This skill comes with accumulating experience."

A nurse has selected several nursing diagnoses in the process of data analysis of a client with poorly controlled type 1 diabetes. One of these diagnoses is Ineffective Health Maintenance related to infrequent blood glucose monitoring as manifested by elevated HgA1C. The nurse recognizes the need to corroborate this diagnosis with the client. How should the nurse best do this? A) "I think you have a nursing diagnosis of Ineffective Health Maintenance." B) "Would you agree that there's room for improvement in your routines around blood sugar monitoring?" C) "After assessing you, I believe that you're not maintaining your health effectively, specifically around your diabetes." D) "How do you think that you could better maintain your health?"

B) "Would you agree that there's room for improvement in your routines around blood sugar monitoring?"

A nurse is preparing to document conclusions after analyzing data, and he or she includes information about related factors and manifestations. The nurse is formulating which of the following? A) Risk nursing diagnosis B) Actual nursing diagnosis C) Collaborative problem D) Problem for referral

B) Actual nursing diagnosis

The nurse is attempting to cluster the data that she collected during the initial assessment of an older adult client. The nurse notes that the client had a swollen left knee and complained of "a bit of soreness" in the joint, but the nurse does not have enough data to support a nursing diagnosis of Impaired Physical Mobility. What should the nurse do next? A) Document a suspected nursing diagnosis of Impaired Physical Mobility. B) Assess the client further for evidence of reduced mobility and decreased range of motion. C) Make a referral to the physical therapist. D) Plan interventions that will conservatively manage the client's joint dysfunction.

B) Assess the client further for evidence of reduced mobility and decreased range of motion.

A nurse has completed a comprehensive assessment of a client and has begun the process of data analysis. Data analysis should allow the nurse to produce which of the following direct results? A) Outcomes evaluation B) Nursing diagnoses C) Holistic interventions D) An interdisciplinary plan of care

B) Nursing diagnoses

A nurse is analyzing the assessment data of a client who has been admitted with exacerbation of heart failure. The nurse has determined that the cue clusters meet the defining characteristics of specific nursing diagnoses. Which of the following would the nurse do next? A) Explain the client's problems to the client and his or her family. B) Verify it with the client and with other health care professionals. C) Validate the diagnosis with the physician. D) Work with the client to begin planning interventions.

B) Verify it with the client and with other health care professionals.

During an educational inservice, nursing have been encouraged to conduct a self-appraisal of their critical thinking skills. Which of the following questions can best guide this appraisal? A) "Do I tend to make errors in my nursing practice?" B) "Do I get good feedback from clients and their families?" C) "Am I open to the fact that I may not be right?" D) "Am I a resource to my colleagues during a crisis?"

C) "Am I open to the fact that I may not be right?"

A nurse has assessed a client and identified data that are associated with the diagnoses of Impaired Physical Mobility and Activity Intolerance. How can the nurse best determine which nursing diagnosis is most applicable to the client? A) Document preliminary conclusions. B) Identify abnormal data. C) Check the defining characteristics of the diagnoses. D) Test the nursing diagnoses clinically.

C) Check the defining characteristics of the diagnoses.

An experienced medical-surgical nurse has identified critical thinking as an integral component of diagnostic reasoning. How can the relationship between these two concepts be best described? A) Critical thinking is the practical application of diagnostic reasoning skills. B) Critical thinking and diagnostic reasoning are synonymous. C) Critical thinking is the foundation of the process of diagnostic reasoning. D) Critical thinking is the domain of the novice nurse, whereas diagnostic reasoning is present in experts.

C) Critical thinking is the foundation of the process of diagnostic reasoning.

A nurse is applying the diagnostic reasoning process in the care of a client with a number of comorbidities. Which of the following descriptions best characterizes Step Two, Clustering Data? A) Hypothesizing of any potentially applicable health promotion diagnoses, risk diagnoses, and actual diagnoses B) Documentation of all professional judgments along with any data that support those judgments C) Examining identified abnormal findings and strengths for cues that are related D) Evaluation of both subjective and objective data to identify strengths and abnormal findings

C) Examining identified abnormal findings and strengths for cues that are related

After teaching a group of students about the second phase of the nursing process, the instructor determines that additional teaching is needed when the students identify which of the following as a component? A) Organizing data B) Clustering data C) Formulating a medical diagnosis D) Generating hypotheses

C) Formulating a medical diagnosis

An experienced nurse is teaching a recently graduated colleague about common pitfalls encountered in the diagnostic reasoning process. The experienced nurse should identify a need for further teaching if the new graduate identifies which of the following as a pitfall? A) View of things as either right or wrong B) Overemphasis on details C) Inclusion of valid data D) Clustering of unrelated cues

C) Inclusion of valid data

A new nursing graduate recently made an oversight during the analysis of a client's assessment data that resulted in a postoperative complication. What characteristic of data analysis makes it a challenging aspect of nursing practice? A) Abnormal data must be identified. B) It requires the prior identification of nursing diagnoses. C) It requires sophisticated diagnostic reasoning skills. D) Conclusions must be clearly and accurately documented.

C) It requires sophisticated diagnostic reasoning skills.

A nurse has identified a goal of developing his critical thinking skills. In order to facilitate this goal, what action should the nurse prioritize? A) Applying quick decision-making B) Seeking new experiences C) Maintaining an open mind D) Maintaining a stable and static knowledge base

C) Maintaining an open mind

A nurse's data analysis has led to the formulation of a risk nursing diagnosis. Which of the following best demonstrates accurate documentation of a risk nursing diagnosis? A) Risk for fatigue related to increased job demands, as manifested by feelings of exhaustion and frequent naps B) Risk for infection, as manifested by lack of client knowledge of wound care C) Risk for violence related to history of overt, aggressive acts D) Risk for altered respiratory function related to environmental allergens, as manifested by asthma

C) Risk for violence related to history of overt, aggressive acts

The nurse has collected objective and subjective data during the assessment of a client who has been admitted for the treatment of an exacerbation of chronic obstructive pulmonary disease (COPD). During the current phase of the diagnostic reasoning process, the nurse is writing down thoughts about each cue cluster of data that was collected. The nurse is involved in which step of the diagnostic reasoning process? A) Step One: Identify Abnormal Data and Strengths B) Step Two: Cluster Data C) Step Three: Draw Inferences D) Step Four: Propose Possible Nursing Diagnoses

C) Step Three: Draw Inferences

A nurse has been clustering the data that he collected during the initial assessment of a frail elderly client. When making inferences about the data clusters, the nurse is unsure whether to associate a cluster of data with a nursing diagnosis or with a collaborative problem. What question may best guide the nurse's decision? A) "Can an unlicensed care provider meet this person's needs?" B) "Is this problem acute or is it chronic?" C) "Can this issue be addressed on an outpatient basis?" D) "Does this issue require medical intervention?"

D) "Does this issue require medical intervention?"

A nurse is caring for a client who has been admitted with an infected venous ulcer. The nurse determines that the client will need medical interventions as well as nursing interventions. The nurse would identify which of the following? A) Actual nursing diagnosis B) Referral C) Risk nursing diagnosis D) Collaborative problem

D) Collaborative problem

During the assessment interview, the client made numerous statements that suggested his life generally exists in a state of harmony and balance. This fact would most likely prompt the nurse to identify which of the following? A) Actual nursing diagnosis B) Risk nursing diagnosis C) Collaborative problem D) Health promotion diagnosis

D) Health promotion diagnosis

A hospital nurse has identified a need to improve her critical thinking skills in an effort to improve client care. The nurse should identify which of the following characteristics of critical thinking? A) It is an innate skill that some individuals possess and which others do not. B) It does not include past experiences. C) It is based primarily on getting correct and timely information. D) It involves reflections on thoughts before reaching conclusions.

D) It involves reflections on thoughts before reaching conclusions.

The nurse's assessment of a client with a decreased level of consciousness reveals that the client is incontinent of urine. During the process of data analysis, the nurse would be justified in identifying what risk nursing diagnosis? A) Risk for Injury related to urinary incontinence B) Risk for Infection related to urinary incontinence C) Risk for Bowel Incontinence related to urinary incontinence D) Risk for Impaired Skin Integrity related to urinary incontinence

D) Risk for Impaired Skin Integrity related to urinary incontinence

Data analysis of assessment data from a client who presented to the emergency department has resulted in the nurse making a syndrome nursing diagnosis. What is a primary characteristic of this type of diagnosis? A) The client's health problem cannot be conveyed using standard nursing language. B) The client's current signs and symptoms are the result of a longstanding health problem. C) The client has health problems that will require multidisciplinary care. D) The client has a number of nursing diagnoses that typically occur together.

D) The client has a number of nursing diagnoses that typically occur together.

A nurse is planning a client's care following the completion of an initial assessment. When formulating a risk nursing diagnosis, which piece of data would be most useful? A) The client has an elevated white blood cell count. B) The client is 66 years of age. C) The client has pain in her joints, especially in the morning. D) The client is separated from her usual social supports.

D) The client is separated from her usual social supports.

A nurse is applying the diagnostic reasoning process in the care of a client. What is the correct sequence of the steps that the nurse should perform? A)Check for defining characteristics. B)Draw inferences. C) Propose possible nursing diagnoses. D)Identify abnormal data and strengths. E) Cluster data.

D,E,B,C,A