Chapter 7: Nursing Diagnosis
A nurse is treating a client with congestive heart failure. The client reports having difficulty walking up the stairs at home and barely being able to walk to the store. Which is an accurate actual nursing diagnosis for this client?
Activity Intolerance related to congestive heart failure as evidenced by inability to walk up and down stairs
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
A nurse has selected a nursing diagnosis and is preparing to validate it. With whom would the nurse do this?
Client
A student identifies fatigue as a health problem and nursing diagnosis for a client receiving home care for treatment of metastatic cancer. What statement or question by the nurse to the client would be best to validate this client problem?
"I think fatigue is a problem for you. Do you agree?"
The nurse has been assigned to a group of clients. Which client should be the nurse's priority?
A 32-year-old client with a urinary tract infection who is receiving an intravenous antibiotic and reporting swelling in the tongue.
Which provides the nurse with the most reliable basis on which to formulate a nursing diagnosis?
A cluster of several significant cues of data that suggest a particular health problem
A pregnant client asks the nurse for information on breastfeeding. What type of nursing diagnosis should the nurse formulate?
A health promotion 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
A nurse develops the nursing diagnoses "Appendicitis" and "Acute Pain" for a client. Which of the diagnoses is a medical diagnosis?
Appendicitis
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
Which example of client care is not the responsibility of the nurse?
Confirming a medical diagnosis
A nurse in the emergency room, who is unfamiliar with pediatric clients, assesses the vital signs of a 1-month old infant with a heart rate of 124 and a respiratory rate of 36. What would be the mostappropriate measure for the nurse to take to analyze the significance of the infant's vital signs?
Consult reference materials to determine the normal vital signs for 1-month old infants.
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.
A client undergoing chemotherapy for breast cancer has lost all hair. The client states, "I cannot stand to see myself without hair. I am disgusting." What would be the most appropriate nursing diagnosis for the nurse to use to address this client's problem?
Disturbed Body Image related to loss of hair
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
Which describes the best approach for the development of nursing diagnoses?
Develop nursing diagnoses from clusters of significant data.
A nurse documents the following nursing diagnosis on a client's plan of care: "Fluid Volume Deficit related to gastrointestinal upset from food poisoning as evidenced by vomiting and diarrhea for the past three days, slow skin turgor, and weight loss." The nurse identifies which part of the statement as the etiology?
Gastrointestinal upset from food poisoning
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
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 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
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
Which is an actual nursing diagnosis?
Impaired Urinary Elimination
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 nurse is formulating a nursing diagnosis for a client with a respiratory disease. Which nursing diagnosis would be correct?
Ineffective Airway Clearance related to thick mucus
The client is being seen for chest congestion, coughing up thick secretions, and shortness of breath for several days and is diagnosed with pneumonia. The client has a two-pack-per-day smoking habit. When developing the plan of care, what would be a priority nursing diagnosis for this client?
Ineffective Airway Clearance related to tracheobronchial secretions as evidenced by expectorating thick, yellow secretions
Which is the best example of a nursing diagnosis?
Ineffective Breastfeeding related to latching as evidenced by nonsustained suckling at the breast.
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
A client with diabetes mellitus has been admitted to the intensive care unit with a serum glucose reading of 400 mg/dL (22.20 mmol/L). Because the care for this client will involve multiple disciplines, which diagnostic statement would be most appropriate for the nurse to select?
PC: Hyperglycemia related to uncontrolled serum glucose
The nurse is admitting a client who is unable to identify person, place, or time. To properly analyze these data, what action must the nurse take?
Interview the client's family to assess the client's usual level of cognition.
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
The sclerae of a 3-day-old infant have a yellowish tint, and the nurse has just received an order to initiate phototherapy. Which nursing diagnosis should the nurse use to plan care for this client?
Neonatal Jaundice
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.
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
Which guideline for composing a nursing diagnosis statement is correct?
Place defining characteristics after the etiology and link them by the phrase "as evidenced by."
A nurse is formulating a nursing diagnosis for a client who is reliving a brutal mugging that took place several months ago. The client reports having flashbacks of the experience and fear of leaving the house alone. Which nursing diagnosis for this client is a NANDA-I-approved problem statement and correctly written?
Post-trauma Syndrome related to being attacked
Which type of nursing diagnosis is validated by the presence of major defining characteristics?
Problem-focused
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
Which nursing diagnosis is an example of a health promotion diagnosis?
Readiness for Enhanced Parenting
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
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
A nurse is educating a client about care to be taken in nephrotic syndrome. The client expresses that the education is of no use because the disease is not curable. What nursing diagnosis should the nurse formulate with regard to the client's concern?
Risk for Powerlessness
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."
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.
A nursing diagnosis is written as Disturbed Body Image related to presence of large scar over left side of face. What does the phrase "Disturbed Body Image" identify?
The health state or problem of the client
Which of the following reflects the diagnosis phase?
The nurse identifies that the client does not tolerate activity.
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."
in addition to identifying responses to actual or potential health problems, what is another purpose of the diagnosing step in the nursing process?
To identify etiologies of health problems
A nursing instructor is describing the components of an actual nursing diagnosis. Which statement would the instructor include as a characteristic feature of diagnostic labels?
describes the essence of the problem using as few words as possible
The primary purpose of nursing diagnoses is to:
guide selection of nursing interventions to meet expected outcomes.
A nurse formulates a nursing diagnosis of "constipation related to adverse effect of opioid analgesic as evidenced by no bowel movement in 4 days." The nurse identifies the defining characteristic as:
no bowel movement in 4 days.
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.
