Chapter 17 Nursing 100

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?

"Do you feel like you need to go to the bathroom?"

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

"How many bowel movements a day have you had?"

A nurse is developing nursing diagnoses for a patient. Beginning with the first step, place in order the steps the nurse will use. 1. Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma. 2. Writes a diagnostic label of impaired gas exchange. 3. Organizes data into meaningful clusters. 4. Interprets information from patient. 5. Writes an etiology.

1,3,4,2,5

A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse document?

Decreased cardiac output related to altered myocardial contractility.

The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, reports of shortness of breath when getting out of bed, and a productive cough. Which elements will the nurse identify as defining characteristics for the diagnostic label of Activity intolerance?

Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed

A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge nurse to follow up?

Developing nursing diagnoses before completing the database

A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?

Impaired gas exchange related to alveolar-capillary membrane changes

After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse's actions?

To distinguish the nurse's role from the physician's role

A nurse adds the following diagnosis to a patient's care plan: 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 abdominal pain. Which element did the nurse write as the defining characteristic?

abdominal distention

A patient presents to the emergency department following a motor vehicle crash that causes 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 reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?

acute pain

Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved?

acute pain

A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The NAP states that 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. In which phase of the nursing process did the nurse first make an error?

assessment

A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. The nurse analyzes the data. Which nursing diagnosis will the nurse assign to the patient?

deficient fluid volume

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 lab results 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?

diagnosis

A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What phrase is used to identify what the nurse is doing?

diagnostic reasoning

A nurse performs an assessment on a patient. Which assessment data will the nurse use as an etiology for acute pain?

disruption of tissue integrity

The 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. Which part of the diagnostic statement does the nurse need to revise?

etiology

A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?

health promotion

A new nurse writes the following nursing diagnoses on a patient's care plan. Which nursing diagnosis will cause the nurse manager to intervene?

hemorrhage

A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to the patient's care plan?

impaired skin integrity