Fundamentals of nursing Ch 17

What are the different types of nursing diagnoses, according to NANDA-I? Select all that apply. 1 Risk diagnoses 2 Acute diagnoses 3 Problem-focused diagnoses 4 Chronic diagnoses 5 Health promotion diagnoses

1 Risk diagnoses 3 Problem-focused diagnoses 5 Health promotion diagnoses

The nurse identified that the patient has pain of 7 on a scale of 1 to 10; he winces during movement, and he expresses discomfort over the incisional area. He guards the area by resisting movement. The incision appears to be healing, but there is natural swelling. What would be the P in a three-part nursing diagnostic statement using the PES format? 1 Severe pain 2 Natural swelling 3 Related to incisional trauma 4 Wincing, guarding, restricted turning and positioning

1 Severe pain

The nurse is assessing a patient's data for the related factor of the nursing diagnosis. Which statements are true regarding the related factor? Select all that apply. 1 The related factor is within the domain of nursing practice. 2 The related factor does not always respond to nursing interventions. 3 In the case of a risk nursing diagnosis, the risk factor is the related factor. 4 The related factor is not associated with the patient's actual response to a health problem. 5 The related factor is identified from the patient's assessment data

1 The related factor is within the domain of nursing practice. 3 In the case of a risk nursing diagnosis, the risk factor is the related factor. 5 The related factor is identified from the client's assessment data.

In the given examples, which nurses are making nursing diagnostic errors? Select all that apply. 1 A nurse listens to lungs for the first time and is not sure if abnormal lung sounds are present. 2 After reviewing objective data, a nurse selects a diagnosis of fear before asking the patient to discuss her feelings. 3 A nurse uses an incorrect diagnostic label. 4 A nurse considers a patient's cultural background when reviewing cues. 5 A nurse prepares to complete a decision on diagnosis and realizes that clinical criteria are grouped incorrectly to form a pattern

1 A nurse listens to lungs for the first time and is not sure if abnormal lung sounds are present. 2 After reviewing objective data, a nurse selects a diagnosis of fear before asking the patient to discuss her feelings. 3 A nurse uses an incorrect diagnostic label 5 A nurse prepares to complete a decision on diagnosis and realizes that clinical criteria are grouped incorrectly to form a pattern

The nurse is attending to a patient in a coronary care unit. She is revising the care plan after evaluating the patient outcomes. Which steps of the nursing processes is the nurse performing? Select all that apply. 1 Assessment 2 Evaluation 3 Implementation 4 Planning 5 Diagnosis

1 Assessment 2 Evaluation

Which errors may occur when the nurse makes the nursing diagnosis prior to grouping all data? 1 Errors in data clustering 2 Errors in data collection 3 Errors in the diagnostic statement 4 Errors in interpretation and analysis of data

1 Errors in data clustering

A patient complains of pain when swallowing solid food. The nurse asks the patient if he or she has a history of substance abuse that has caused this pain. What kind of diagnostic error is does the nurse make in this scenario? 1 Errors in data collection 2 Errors in data clustering 3 Errors in the diagnostic statement 4 Errors in interpretation and analysis of data

1 Errors in data collection

The nurse is caring for a football player scheduled for ankle surgery. The patient communicates properly during the interview. The nurse finds a quiver in the patient's voice as he expresses his worry about not being able to play. The nurse observes that the patient has fidgety hands and legs. The nurse concludes that the patient is uncertain about his ability to play postsurgery. What interventions should the nurse implement to reduce anxiety in the patient? Select all that apply. 1 Explain the recovery process to the patient. 2 Provide detailed instructions about the surgery. 3 Consult with a psychologist regarding the patient's behavior. 4 Teach postoperative care to the patient and his caregiver. 5 Encourage health-promotion activities such as exercise and routine social activities

1 Explain the recovery process to the patient. 2 Provide detailed instructions about the surgery 4 Teach postoperative care to the patient and his caregiver

What is a health promotion diagnosis, according to NANDA-I? 1 It describes a person's readiness to enhance specific health behaviors for well-being. 2 It describes human responses to health conditions that may develop in a vulnerable individual. 3 It describes human responses to health conditions that exist in an individual or community. 4 It is associated with a potential response to the health problem and can change by using specific nursing interventions

1 It describes a person's readiness to enhance specific health behaviors for well-being

Inaccurate data collection is a source of error in diagnosis. What factors can cause errors in data collection? Select all that apply. 1 Missing data 2 Inaccurate data 3 Disorganization 4 Lack of knowledge or skill 5 Premature or early closure of clustering

1 Missing data 2 Inaccurate data 3 Disorganization 4 Lack of knowledge or skil

A patient is anxious about an operation scheduled for the next day. The nurse identifies that the patient is anxious. Which interventions does the nurse use to decrease the patient's anxiety related to surgery? Select all that apply. 1 Provide satisfactory answers to the patient's questions. 2 Instruct the patient to perform range-of-motion exercises. 3 Provide detailed instructions about the recovery process. 4 Provide detailed instructions about the surgical procedure. 5 Provide detailed instructions about discharge planning

1 Provide satisfactory answers to the patient's questions. 3 Provide detailed instructions about the recovery process. 4 Provide detailed instructions about the surgical procedur

The nurse is assessing a patient who has asthma. How would the nurse arrange the steps in the correct sequence for making a nursing diagnosis? 1. Assessing of patient's health status 2. Data clustering 3. Selecting the diagnostic label 4. Validating data with other sources

1.Assessing patient's health status 2. Validating data with other sources 3. Data clustering 4. Selecting the diagnostic label

The nurse is teaching nursing students about medical diagnoses. Which statements by the students indicate effective learning? Select all that apply. 1 "Acute pain is a medical diagnosis." 2 "Osteoarthritis is a medical diagnosis." 3 "A medical diagnosis includes the clinical judgment about an individual and his family." 4 "Medical diagnoses are based on the results of diagnostic tests." 5 "A primary healthcare provider is licensed to describe medical diagnoses.

2 "Osteoarthritis is a medical diagnosis." 4 "Medical diagnoses are based on the results of diagnostic tests." 5 "A primary healthcare provider is licensed to describe medical diagnoses.

The nurse completed the following assessment: 63-year-old female patient has had abdominal pain for 6 days. She reports not having a bowel movement for 4 days, whereas she normally has a bowel movement every 2 to 3 days. She has not been hospitalized in the past. Her abdomen is distended. She reports being anxious about upcoming tests. Her temperature was 37° C, pulse 82 and regular, blood pressure 128/72. Which data form a cluster, showing a relevant pattern? Select all that apply. 1 Vital sign results 2 Abdominal distention 3 Age of patient 4 Change in bowel elimination pattern 5 Abdominal pain 6 No history of hospitalization

2 Abdominal distention 4 Change in bowel elimination pattern 5 Abdominal pain

A patient is diagnosed with urinary stress incontinence. The nurse identifies it as which type of diagnosis? 1 Risk diagnosis 2 Actual diagnosis 3 Chronic diagnosis 4 Health promotion diagnosis

2 Actual diagnosis

According to the NANDA International, what are the categories of sources of error that may occur in the nursing diagnostic process? Select all that apply. 1 Implementing 2 Collecting 3 Clustering 4 Evaluating 5 Interpreting

2 Collecting 3 Clustering 5 Interpreting

The nurse in a geriatric clinic collects the following information from an 82-year-old patient and her daughter, the family caregiver. The daughter explains that the patient is "always getting lost." The patient sits in the chair but gets up frequently and paces back and forth in the examination room. The daughter says, "I just don't know what to do because I worry she will fall or hurt herself." The daughter states that, when she took her mother to the store, they became separated, and the mother couldn't find the front entrance. The daughter works part-time and has no one to help watch her mother. Which of the data form a cluster, showing a relevant pattern? Select all that apply. 1 Daughter's concern for mother 2 Pacing 3 Client getting lost easily 4 Daughter working part-time 5 The patient getting up frequently

2 Pacing 3 Client getting lost easily 5 The patient getting up frequently

Following an assessment, the nurse is formulating a nursing diagnosis using the PES format. What does the P in the acronym PES stand for? 1 Period 2 Problem 3 Prevention 4 Predication

2 Problem

The nurse is assessing patients on the unit. What activities would the nurse perform during the diagnostic phase of the nursing process? Select all that apply. 1 Teach the patient about preventative measures. 2 Review information collected about the patient. 3 Find cues and patterns in the patient's data. 4 Make conclusions related to health problems. 5 Implement the care necessary for the patient.

2 Review information collected about the patient 3 Find cues and patterns in the patient's data. 4 Make conclusions related to health problems

The nurse is preparing a diagnostic statement for a patient who has diabetes. What is the most appropriate step the nurse should take in this scenario? 1 The nurse should identify the nursing intervention, not the patient problem. 2 The nurse should identify nursing diagnoses from a cluster of defining characteristics and not just a single symptom. 3 The nurse should identify the medical diagnosis rather than the patient's response when creating the statement. 4 The nurse should identify the treatment or the study itself, rather a problem caused by the treatment or diagnostic study

2 The nurse should identify nursing diagnoses from a cluster of defining characteristics and not just a single symptom

Which patient-related factors fall under health promotion nursing diagnosis? Select all that apply. 1 The patient follows poor hygiene measures. 2 The patient is willing to eat nutritious foods. 3 The patient shows decreased interaction with society. 4 The patient is ready to increase his or her coping skills. 5 The patient is ready to perform regular exercises

2 The patient is willing to eat nutritious foods. 4 The patient is ready to increase his or her coping skills. 5 The patient is ready to perform regular exercises

The nurse is caring for a patient who has been admitted to the hospital with pneumonia. Which assessment findings of the patient can the nurse group together to formulate a data cluster? Select all that apply. 1 Dysuria 2 Wheezing in left lung bases 3 Respiration 20 breaths/minute 4 Weakness of the entire body 5 Shortness of breath with ambulation

2 Wheezing in left lung bases 3 Respiration 20 breaths/minute 5 Shortness of breath with ambulation

A nurse is teaching a group of nursing students about the usage of NANDA-I terminologies in the medical record entry. Which statements by the student indicates the need for further education? Select all that apply. 1 " NANDA-I diagnoses have a broad literature base." 2 "NANDA-I classifications are most comprehensive." 3 "NANDA-I diagnoses do not comprise evidence-based diagnoses." 4 "NANDA-I diagnoses emphasize precise documentation of health problems." 5 "NANDA-I diagnoses are refined by the primary health care provider on a regular basis."

3 "NANDA-I diagnoses do not comprise evidence-based diagnoses." 5 "NANDA-I diagnoses are refined by the primary health care provider on a regular basis.

A patient diagnosed with pancreatitis complains of pain in the abdomen. Following an initial interview and the assessment, the nurse prepares a nursing care plan. Which guidelines should the nurse follow to reduce errors in the diagnostic statement? Select all that apply. 1 Identify medical diagnoses. 2 Identify clinical signs and symptoms. 3 Identify treatable etiology or risk factors. 4 Identify the problems caused by the treatment. 5 Identify the patient's response

3 Identify treatable etiology or risk factors. 4 Identify the problems caused by the treatment. 5 Identify the patient's response

What is the benefit of an accurate nursing diagnosis? 1 It decreases the side effects of medications. 2 It reduces the cost of treatment to the patient. 3 It helps ensure effective and efficient nursing interventions. 4 It prevents further assessment.

3 It helps ensure effective and efficient nursing interventions.

Which term describes data that appear to show some type of patterned relationship with a nursing diagnosis? 1 Data cluster 2 Concept map 3 Related factors 4 Defining characteristic

3 Related factors

The nurse identified that the patient has pain of 7 on a scale of 1 to 10; he winces during movement, and he expresses discomfort over the incisional area. He guards the area by resisting movement. The incision appears to be healing, but there is natural swelling. What would be the E in a three-part nursing diagnostic statement using the PES format? 1 Severe pain 2 Natural swelling 3 Related to incisional trauma 4 Wincing, guarding, restricted turning and positioning

3 Related to incisional trauma

A student nurse is gathering information from an elderly patient. Which of the student nurse's actions indicates the need for further teaching? 1 Maintaining good eye contact with the patient 2 Giving more time for the patient to answer questions 3 Sitting straight in the chair while talking with the patient 4 Nodding his or her head in response to the patient's words

3 Sitting straight in the chair while talking with the patient

In the examples given, which nurses are making nursing diagnostic errors? Select all that apply. 1 The nurse who listens to lung sounds after a patient reports difficulty breathing 2 The nurse who considers conflicting cues in deciding which diagnostic label to choose 3 The nurse who is assessing the edema in a patient's lower leg and is unsure how to assess the severity of edema 4 The nurse who identifies a diagnosis based on a single defining characteristic 5 The nurse who identifies a risk-for diagnosis related to a medical diagnosis

3 The nurse who is assessing the edema in a patient's lower leg and is unsure how to assess the severity of edema 4 The nurse who identifies a diagnosis based on a single defining characteristic

The nurse is teaching a group of nursing students about the application of a nursing diagnosis to nursing practice. Which statement made by a student indicates the need for further teaching? 1 "Nursing diagnosis helps with the identification of patient health problems." 2 "Nursing diagnosis offers an approach to ensure comprehensive nursing assessment." 3 "Research gives backing to nursing diagnoses that are used to identify a patient's health care problem." 4 "Nursing diagnosis improves the selection of nursing interventions by nurses in certain practice settings."

4 "Nursing diagnosis improves the selection of nursing interventions by nurses in certain practice settings."

What is a clinical judgment that concerns motivation and desire to increase well-being and actualize human health potential? 1 Medical diagnosis 2 Risk nursing diagnosis 3 Problem-focused nursing diagnosis 4 Health promotion nursing diagnosis

4 Health promotion nursing diagnosis

Which is an example of an interpreting error in nursing diagnostics? 1 Inaccurate data 2 Disorganization 3 Failure to seek guidance 4 Inaccurate understanding of cues

4 Inaccurate understanding of cues

A patient's caregiver asks the nurse, "Can I view the patient's medical records?" What should the nurse do in this situation? 1 Report to the primary healthcare provider immediately, by placing a call to the office. 2 Ignore the caregiver's request and carry on with the work; if it comes up again, address it. 3 Respect the caregiver's wish and show the patient's medical records to adequately provide care. 4 Politely tell the caregiver that disclosing the medical records to others is not in accordance with the law

4 Politely tell the caregiver that disclosing the medical records to others is not in accordance with the law

The nurse identified that the patient has pain of 7 on a scale of 1 to 10; he winces during movement, and he expresses discomfort over the incisional area. He guards the area by resisting movement. The incision appears to be healing, but there is natural swelling. What would be the S in a three-part nursing diagnostic statement using the PES format? 1 Severe pain 2 Natural swelling 3 Related to incisional trauma 4 Wincing, guarding, restricted turning and positioning

4 Wincing, guarding, restricted turning and positioning

Which type of interpretation errors may occur with a nursing diagnosis? Select all that apply. 1 Inaccurate interpretation of cues 2 Use of an insufficient number of cues 3 Failure to consider conflicting cues 4 Failure to validate the nursing diagnosis with the patient 5 Insufficient cluster of cues

Correct 1 Inaccurate interpretation of cues Correct 2 Use of an insufficient number of cues Correct 3 Failure to consider conflicting cues