Ch. 15

After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type?

Actual

"Acute Pain related to instillation of peritoneal dialysate as evidenced by client wincing and grimacing during procedure, client description of experience as 'stabbing'" is an example of which type of nursing diagnosis?

Actual nursing diagnosis

Which type of health problem requires both physician- and nurse-prescribed actions to address?

Collaborative health problem

A client is caring for the client's mother-in-law, who is an older adult who requires assistance with performing activities of daily living. Which statement by the client would lead the nurse to make a nursing diagnosis of Caregiver Role Strain?

"I just don't have time to take a shower."

A pregnant client asks the nurse for information on breastfeeding. What type of nursing diagnosis should the nurse formulate?

A health promotion nursing diagnosis

The nurse caring for a client with obesity would like to address the possible health problems that can develop related to obesity. To plan care for this client, what type of nursing diagnosis would the nurse formulate?

A risk nursing diagnosis

A nurse is caring for an older adult client who is scheduled for a cystoscopy the next day to determine the cause of an overdistended bladder. The client expresses being nervous and informs the nurse that this the first time that the client has been admitted to a health care facility for an illness. Which diagnostic label would the nurse use to formulate the nursing diagnosis?

Anxiety

When planning initial care for a 16-year-old client and the client's newborn, the nurse formulates a nursing diagnosis of "Risk for Impaired Attachment." What would be the nurse's most appropriate action to take next?

Assess the client's interactions with the newborn.

The care plan for a client who has been frequently admitted to the hospital for exacerbation of chronic obstructive pulmonary disease (COPD) includes a nursing diagnosis of "Noncompliance related to lack of knowledge as evidenced by frequent admissions to the hospital." What is the most appropriate method for the nurse to use to validate the nursing diagnosis?

Assess the client's knowledge of COPD.

A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify?

Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor

A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination?

Bowel Incontinence

Which example of client care is not the responsibility of the nurse?

Confirming a medical diagnosis

A newly graduated nurse is unable to determine the significance of data obtained during an assessment. What would be the nurse's most appropriate action?

Consult with a more experienced nurse.

Which assessment findings would support the nursing diagnosis of Impaired Skin Integrity? Select all that apply.

Impaired mobility due to recent stroke Unable to turn in bed without assistance Uncontrolled diabetes

The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this baby, but I have always believed that abortion is a sin. I don't know what to do." What nursing diagnosis would be most appropriate for the nurse to formulate?

Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement

The nurse formulates the following nursing diagnosis: Disturbed Body Image related to decreased ability to cope with surgical removal of right breast as evidenced by the client refusing to look at the surgical site and stating, "I'm ugly. My husband will no longer find me desirable." What is the etiology identified in this nursing diagnosis?

Decreased ability to cope with surgical removal of right breast

Which component of a nursing diagnosis gives additional meaning to the nursing diagnosis?

Descriptors

The nurse is planning care for a client who has experienced a myocardial infarction. Which would likely be appropriate nursing diagnoses for the nurse to select for this client? Select all that apply.

Fear related to change in health status Pain related to cardiac tissue damage

The nurse is caring for a client who has been diagnosed with a sexually transmitted infection (STI). The nurse plans to address the nursing diagnosis of Risk-Prone Behavior. What assumption has the nurse made?

Having an STI means the client is sexually promiscuous.

A nurse documents the following nursing diagnosis on a client's plan of care: "Readiness for Enhanced Breast-Feeding." The nurse has identified which type of nursing diagnosis?

Health promotion

The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping?

Health promotion nursing diagnosis

A nurse is caring for a toddler who has been treated on two different occasions for lacerations and contusions due to the parents' negligence in providing a safe environment. What is an appropriate nursing diagnosis for this client?

High Risk for Injury related to unsafe home environment

A client recently diagnosed with pancreatic cancer tells the nurse, "I don't see any hope for my future." What would be the most appropriate nursing diagnosis for the nurse to formulate to address this health problem?

Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis

When developing a nursing diagnosis for a client, which should the nurse do first?

Identify the significant data

Which would be an appropriate nursing diagnosis for a client with cachexia and decreased weight?

Imbalanced Nutrition: Less than Body Requirements

A nurse is interviewing an older adult client who has experienced a drastic weight loss following a cerebrovascular accident (CVA). The client states, "I have trouble getting groceries because I can no longer drive, so I don't have much food in the house." Based on this evidence, what would be the most appropriate nursing diagnosis?

Imbalanced Nutrition: Less than Body Requirements related to difficulty in procuring food

A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain, which is interfering with the client's ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records?

Impaired Physical Mobility related to pain

A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis?

Ineffective Airway Clearance

A client with diabetes mellitus has been admitted to the hospital in diabetic ketoacidosis. During the admission assessment of the client, the nurse learns that the client is not following the prescribed therapeutic regimen. The client states, "I don't really have diabetes. My doctor overreacts." What is the most appropriate diagnosis for this client's health problem?

Ineffective Health Maintenance related to client's denial of illness

Assessment of a client with difficulty breathing reveals that the client has 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?

Ineffective airway clearance

A nurse is planning education about prescription medications for a client newly diagnosed with asthma. What nursing diagnosis would be most appropriate for the nurse to select?

Knowledge Deficit: Medications related to new medical diagnosis

What association meets every 2 years to further progress in defining, classifying, and describing nursing diagnoses?

NANDA-International (NANDA-I)

The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action?

Notify the physician for additional orders.

The formulation of nursing diagnoses is unique to the nursing profession. Which statement accurately represents a characteristic of diagnosing?

Nurses write nursing diagnoses to describe client problems that nurses can treat.

A nurse documents the following in the client chart: Risk for Decreased Cardiac Output related to myocardial ischemia. This is an example of what aspect of client care?

Nursing diagnosis

A client has been diagnosed with a recent myocardial infarction. What collaborative problem would be the priority for the nurse to address?

PC: Decreased Cardiac Output related to cardiac tissue damage

A community group has requested the public health nurse to present a program describing the advised schedule of immunizations for children. To plan for this program, what nursing diagnosis would be most appropriate for the nurse to select?

Readiness for Enhanced Knowledge: Childhood Immunizations

An older adult client recently admitted to a long-term care facility expresses anger and depression about the relocation. The client consumes very little food and is losing weight. Which nursing diagnosis would be most appropriate for the nurse to select to plan this client's care?

Relocation Stress Syndrome

Which is a legal responsibility of a nurse who has documented a nursing diagnosis related to a client's kidney failure?

Reporting signs and symptoms related to the client's kidney failure

Which error has the nurse made in formulating the following nursing diagnosis: Prolonged Immobility related to impaired skin integrity as evidenced by an open area with a 1-inch diameter on the right buttocks surrounded by a 1-inch margin of redness; wound surface clean and beefy red; no drainage or foul odor detected.

Reversed the health problem and the etiology.

A client admitted for a surgical procedure tells the nurse, "I am very worried because I am allergic to latex. I want to make sure that everyone knows this." To ensure the safety of the client, which nursing diagnosis should the nurse assign to this client and address in the care plan?

Risk for Allergy Response related to latex allergy

A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern?

Risk for Community Contamination related to possible environmental pollution

Which is an accurately phrased risk nursing diagnosis?

Risk for Falls related to altered mobility

Which statement appropriately identifies a risk nursing diagnosis for a client who is confined to bed?

Risk for Impaired Skin Integrity related to bed rest

A client with HIV has been admitted to a health care facility. Which nursing diagnosis should be the priority, keeping in mind the client's condition?

Risk for Infection

Which nursing diagnosis has the priority when caring for an older adult client with Alzheimer disease?

Risk for Injury

The nurse is formulating nursing diagnoses pertaining to a client with pancreatic cancer. Which factors should the nurse identify as strengths of the client? Select all that apply.

The client has been accompanied by family members to every appointment. The client states a belief in a reward in heaven after death. The client has demonstrated effective coping skills in the past.

A nursing diagnosis of "Ineffective Coping" has been chosen for a client after receiving a diagnosis of prostate cancer. What assessments would the nurse consider as evidence for this diagnosis? Select all that apply.

The client reports an inability to get adequate restful sleep. The client has difficulty concentrating on the details of treatment options. The client states, "I can't handle all of this."

A client diagnosed with advanced lung cancer has a nursing diagnosis of Ineffective Coping. What assessment data would provide evidence to the nurse for this diagnosis?

The client states, "I am sure the doctors have misdiagnosed me."

The nurse has identified a nursing diagnosis of "Risk for Impaired Parenting" for a client who has recently learned of being pregnant. What assessment data would be appropriate to lead the nurse to select this diagnosis?

The client states, "I do not know how to take care of a baby."

Which factor is most likely to contribute to the nurse making a diagnostic error?

The client withholds information during the client assessment.

The nurse caring for a client diagnosed with melanoma has identified a nursing diagnosis of "Ineffective Coping." What subjective assessment data would provide evidence for this nursing diagnosis?

The client's report of increased consumption of alcohol

The nurse has selected a nursing diagnosis of "Impaired Home Maintenance" for an older adult client. What assessment data would evidence this diagnosis?

The nurse observes unsafe conditions in the client's home.

When reviewing the client's history, the nurse notes that the client's last documented bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "Constipation," what assessment must the nurse make?

The nurse should determine the client's normal bowel elimination pattern.

During morning report, the night nurse tells the day nurse that the client refused to allow the technician to draw blood for laboratory testing. What step would be essential for the day nurse to complete before selecting a nursing diagnosis to address this issue?

The nurse should determine the reason for the client's refusal

During a home health care visit, the nurse identifies a nursing diagnosis of Caregiver Role Strain for a parent who is caring for a child dependent on a ventilator. What subjective assessment data would support the nurse's diagnosis?

The parent states, "I cannot allow anyone else to help because they won't do it right."

The nurse recognizes that health problems that the nurse can address by independent nursing interventions are called:

actual or potential nursing diagnoses.

A nurse makes a nursing diagnosis of Constipation after a client reports not defecating on the last trip to the bathroom. The nurse has no other information on the client's defecation history. This is an example of:

premature closure.

When developing an appropriate nursing diagnosis, the nurse needs to keep in mind that:

the interventions planned must be within the nurse's scope of practice.

The nurse is aware that nursing diagnoses are:

within the nursing scope of practice to develop and client-focused.