Chapter 12

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 An actual nursing diagnosis A wellness diagnosis A possible nursing diagnosis

A risk nursing diagnosis

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? Client's report of reading the Bible and praying daily Client's report of researching treatment options for melanoma Client's report of increased consumption of alcohol Client's report of eating more fruits and vegetables

Client's report of increased consumption of alcohol

What gives additional meaning to a nursing diagnosis? Descriptors Qualifications Composition Dysfunction

Descriptors

The nurse is admitting a client who is unable to identify person, place, or time. In order to properly analyze this data, what action must the nurse take? Ensure precautions are taken to prevent injury to the client. Interview the client's family to assess the client's usual level of consciousness. Assess the client's vital signs to determine the client's baseline. Determine the client's medical diagnosis for clarification.

Interview the client's family to assess the client's usual level of consciousness.

A nurse suspects that a client has a self-care deficit, but needs more data to confirm this diagnosis. What nursing diagnosis would the nurse write for this client? Actual Possible Apparent Potential

Possible

Which is an accurately phrased risk diagnosis? Risk for Pain After Surgery. Risk for Falls related to altered mobility. Risk for Fluid Volume Excess related to increased oral intake as evidenced by consuming 3 L of soda. Risk for Impaired Coping as evidenced by client crying.

Risk for Falls related to altered mobility.

Which assessment finding would support the nursing diagnosis of Acute Pain? Select all that apply. The client is a heavy cigarette smoker. The client had back surgery 2 years ago and expresses the need for ibuprofen on most days. The client is crying in pain about 20 minutes before her pain medicine is due. The client has a history of osteoarthritis. The client had an abdominal hysterectomy 1 day ago.

The client had an abdominal hysterectomy 1 day ago. The client is crying in pain about 20 minutes before her pain medicine is due.

The nursing diagnosis taxonomy provides nursing with: common language. evaluative care. discharge planning. legal information.

common language.

The nurse formulates the nursing diagnosis: Disturbed Body Image related to decreased ability to cope with surgical removal of right breast AEB client refuses to look at surgical site and client statement, "I'm ugly. My husband will no longer find me desirable." The decreased ability to cope with the removal of the breast is an example of: etiology. defining characteristics. problem. NANDA-I label.

etiology.

When writing an actual nursing diagnosis, the nurse includes the etiology that contributes to the current situation. This would be identified as: diagnostic label. defining characteristics. related factors. problem statement.

related factors.

What is the purpose of establishing a nursing diagnosis? to collaborate with the physician to describe a functional health problem to meet accreditation criteria to identify medical problems

to describe a functional health problem

A nurse has identified a risk nursing diagnosis for a client. When writing this diagnosis, the nurse would write a statement consisting of how many parts? Two Four Three One

Two

A 19-year-old male college basketball player is being evaluated for injuries after a skiing accident. The nurse determines the client has a pulse of 52. What would be the most appropriate way for the nurse to determine the significance of the client's heart rate? Compare the client's heart rate to another teenage client. Have another nurse reassess the heart rate for accuracy. Ask the client if the heart rate is normal to him. Determine if the client has any risk factors for cardiac disease.

Ask the client if the heart rate is normal to him.

When planning initial care for a 16-year-old mother and her newborn, the nurse formulates a nursing diagnosis of "Risk for Impaired Attachment." What would be the nurse's most appropriate action to take next? Direct all education of infant care to the client's mother. Develop a comprehensive education plan for infant care. Initiate referrals to available community services. Assess the client's interactions with her newborn.

Assess the client's interactions with her newborn.

Which of the following is an example of a nursing diagnosis? Hypoglycemia Constipation Dehydration Depression

Constipation Constipation is a nursing diagnosis included in the Elimination domain. Hypoglycemia, dehydration, and depression are examples of medical diagnoses or medical pathology.

What does the nursing diagnosis represent? Cues Maladaptation Signs Symptoms

Cues Each nursing diagnosis represents a pattern of related client cues.

A nurse is caring for a client admitted with dehydration after completing a triathlon in a hot, dry climate. The nurse identifies an appropriate nursing diagnosis for this client as "Deficient Fluid Volume related to insufficient fluid intake as evidenced by blood pressure 84/46, heart rate 145, concentrated urine, and client stating that he drank 200 mL of water during the 4-hour event." Identify the problem statement in this nursing diagnosis. Blood pressure 84/46, heart rate 145, concentrated urine, and tented skin turgor Insufficient fluid intake Hot, dry climate Deficient fluid volume

Deficient fluid volume

Which statement appropriately identifies an at-risk nursing diagnosis for a woman 78 years of age who is confined to bed? Potential for pneumonia related to inactivity Risk for impaired skin integrity related to bed rest Immobility related to confinement to bed Ineffective airway clearance related to bed rest

Risk for impaired skin integrity related to bed rest

Which nursing diagnosis has the priority when caring for an older adult client with Alzheimer disease? Risk for injury Impaired memory Self-care deficit Impaired physical mobility

Risk for injury

The nurse is formulating a nursing diagnosis for a client after completing an assessment. What is the greatest benefit of the nursing diagnosis when creating the nursing care plan? Select all that apply. improves communication between nurses caring for the client allows nurses to practice without accountability to other health disciplines encourages the client's participation in care standardizes the care provided by members of other health disciplines directs areas of nursing research

improves communication between nurses caring for the client directs areas of nursing research encourages the client's participation in care

One major requirement of a nursing diagnosis is that it focuses on a problem that is: established by the physician. legally treatable by registered nurses. based on the client's pathophysiology. included within the diagnosis-related group.

legally treatable by registered nurses.

Which nursing actions would take place during the diagnosis stage of the nursing process? Select all that apply. The nurse assists the client with ambulation to the bathroom. The nurse identifies that the client has effectively coped with health stressors in the past. The nurse determines that the client needs to have a decrease in activity. "Based on what you have told me, it seems that urinary incontinence is a problem for you. What do you think?" The nurse identifies that the client who is on strict bed rest is at risk for impaired skin integrity.

"Based on what you have told me, it seems that urinary incontinence is a problem for you. What do you think?" The nurse identifies that the client has effectively coped with health stressors in the past. The nurse identifies that the client who is on strict bed rest is at risk for impaired skin integrity. The nurse determines that the client needs to have a decrease in activity.

A client has been diagnosed with appendicitis and scheduled for an open appendectomy. How should the nurse document a potential complication related to this client's diagnosis and treatment? "Potentially complicated respiration as a result of surgery" "Risk for respiratory arrest due to anesthesia" "Client is at risk of impaired lung function due to anesthesia." "PC: Atelectasis related to surgery"

"PC: Atelectasis related to surgery" To write a diagnostic statement for a collaborative problem, focus on the potential complications of the problem. Use "PC" (for potential complication), followed by a colon, and list the complications that might occur. For clarity, link the potential complications and the collaborative problem by using "related to." (less)

A nurse is treating a client with congestive heart failure. The client informs the nurse that he is having difficulty walking up the stairs in his home and can barely walk to the store. Which is an accurate actual nursing diagnosis for this client? Noncompliance with new diagnosis of congestive heart failure. Activity Intolerance as evidenced by inability to walk up and down stairs and inability to walk to the store. Activity Intolerance related to congestive heart failure as evidenced by inability to walk up and down stairs. Risk for Impaired Coping related to congestive heart failure.

Activity Intolerance related to congestive heart failure as evidenced by inability to walk up and down stairs. When considering the responses, first check for sentence structure. Only one of the choices contains the three elements of the nursing diagnosis: the diagnostic label, the related factors, and the defining characteristics. The question asks for an actual diagnosis; this eliminates any risk, wellness, or potential diagnoses.

A nurse has selected a nursing diagnosis and is preparing to validate it. With whom would the nurse do this? Another staff nurse Client's health care provider The unit's nurse manager Client

Client

Nursing diagnoses that require physician-prescribed and nurse-prescribed actions would be what type of problems? Interdisciplinary health problems Independent health problems Collaborative health problems Physician-developed problems

Collaborative health problems

While developing a plan of care for a client, what should the nurse do before selecting a nursing diagnosis? Establish short- and long-term client goals. Verify the primary care provider's written orders. Perform a focused assessment related to the reason for admission. Collect client subjective and objective data.

Collect client subjective and objective data.

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 most appropriate measure for the nurse to take to analyze the significance of the infant's vital signs? Perform a complete physical assessment to determine the cause of the elevated vital signs. Report the vital signs and allow the emergency room physician to determine the significance. Consult reference materials to determine the normal vital signs for 1-month old infants. Ask the mother if the infant's heart rate is higher than normal.

Consult reference materials to determine the normal vital signs for 1-month old infants.

The nurse formulates the following nursing diagnosis: Disturbed Body Image related to decreased ability to cope with surgical removal of right breast. The client refuses to look at surgical site and states, "I'm ugly. My husband will no longer find me desirable." What is the etiology? "I'm ugly. My husband will no longer find me desirable." Decreased ability to cope with surgical removal of right breast Disturbed body image Refusal of client to look at surgical site

Decreased ability to cope with surgical removal of right breast

A client with advanced Alzheimer's disease has a nursing diagnosis of "Risk for Aspiration." What would the nurse select as an appropriate etiology for this diagnosis? Decreased level of consciousness Choking episode Fluids entering the client's airway Alzheimer's disease

Decreased level of consciousness

A client who is scheduled for coronary angioplasty is concerned if the surgery is safe and wonders whether it would be beneficial. Which nursing diagnosis relates to this client's condition? Knowledge Deficit: treatment regimen related to surgical outcomes Anxiety related to fear of death during surgery Ineffective Coping related to anxiety and fear of surgery Fear related to potential risk and surgical outcomes

Fear related to potential risk and surgical outcomes

A client, whose care plan includes a nursing diagnosis of "Risk for infection related to a disruption of skin integrity secondary to abdominal surgery", is displaying redness, edema, and warmth at the surgical site. What would be the nurse's most appropriate revision of the care plan? Revise the nursing diagnosis to include prescribed medication for infection. Formulate the medical diagnosis "Wound infection related to infectious processes." Revise the nursing diagnosis to "Infection as evidenced by redness, edema, and warmth at the surgical site." Formulate the collaborative problem "PC: Infection related to disrupted skin integrity."

Formulate the collaborative problem "PC: Infection related to disrupted skin integrity."

A nurse is developing the plan of care for a client and establishes several nursing diagnoses based on assessment data. The nurse demonstrates an understanding of nursing diagnoses by focusing on which area? Problem validation through physician collaboration Actions to be initiated for treatment Pathophysiologic responses occurring in body systems Human responses to actual or potential health problems

Human responses to actual or potential health problems

In the development of a nursing diagnosis for a client who has cachexia and decreased weight, what would be an appropriate nursing diagnosis? Imbalanced nutrition: less than body requirements Lack of adequate nutrition related to decreased calories Weight loss related to abdominal discomfort Anorexia nervosa and bulimia

Imbalanced nutrition: less than body requirements

A nurse is interviewing an asthmatic client who has a high respiratory rate and is having difficulty breathing. The client is consequently restless and can only speak a few words before pausing to catch her breath. What appropriate nursing diagnosis should the nurse document? Impaired Verbal Communication related to the breathing problem Impaired Gas Exchange related to the disease condition Inability to Speak due to ineffective airway clearance Impaired Physical Mobility related to tachypnea

Impaired Verbal Communication related to the breathing problem

What is meant by impaired state of equilibrium? It describes the client's condition. It assists in planning care. It is common terminology. It is a nursing diagnosis.

It describes the client's condition.

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? Ineffective Airway Clearance related to bronchial constriction Noncompliance related to deficient knowledge of a new medical diagnosis Anticipatory Grieving related to chronic illness management Knowledge deficit: Medications related to new medical diagnosis

Knowledge deficit: Medications related to new medical diagnosis

The formulation of nursing diagnoses is unique to the nursing profession. Which statement accurately represents a characteristic of diagnosing? Nursing diagnoses remain the same for as long as the disease is present. Nurses write nursing diagnoses to describe client problems that nurses can treat. Nurses formulate nursing diagnoses to identify diseases. Nursing diagnoses focus on identifying healthy responses to health and illness.

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? Collaborative problem Nursing assessment Nursing diagnosis Medical diagnosis

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: Fear related to new diagnosis of myocardial infarction PC: Disturbed body image related to decreased activity tolerance PC: Activity intolerance related to decreased oxygenation capacity PC: Decreased cardiac output related to cardiac tissue damage

PC: Decreased cardiac output related to cardiac tissue damage

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? Risk for unstable blood glucose related to diabetes Diabetes mellitus as evidenced by serum glucose of 400 mg/dL (22.20 mmol/L) Need for glucose control as evidenced by hyperglycemia PC: Hyperglycemia related to uncontrolled serum glucose

PC: Hyperglycemia related to uncontrolled serum glucose

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? Risk for Infection Transmission related to lack of immunizations Readiness for enhanced knowledge: childhood immunizations Ineffective Health Maintenance related to lack of knowledge of childhood immunizations Risk for Complications related to childhood illnesses

Readiness for enhanced knowledge: childhood immunizations

Which error has the nurse made in formulating the following nursing diagnosis: Prolonged Immobility related to impaired skin integrity AEB 1-inch diameter open area on right buttocks surrounded by a 1-inch margin of redness; wound surface clean and beefy red; no drainage or foul odor detected. Identified environmental factors rather than client factors as the problem Writing the diagnosis in terms of a need rather than a client response Reversed the health problem and the etiology Omitted the defining characteristics of the client health problem

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." In order to assure the safety of the client, what nursing diagnosis would the nurse address? Knowledge Deficit related to surgical procedure Risk for Injury related to latex allergy Anxiety related to surgical procedure Risk for Allergy Response related to latex allergy

Risk for Allergy Response related to latex allergy

A client has been admitted to a hospital suffering from an acute psychotic episode. What assessment data would the nurse identify as this client's strengths? Select all that apply. The client is willing to attend counseling sessions. The client has ample financial resources. The client is male and 35 years old. The client refuses to take the ordered medication. The client has been living on the street for 3 weeks.

The client has ample financial resources. The client is willing to attend counseling sessions.

The nurse is caring for a client who underwent surgery 1 day ago. Which client problem can be addressed by independent nursing diagnoses? The client has a blood pressure of 160/95 mm Hg. The client has diminished breath sounds. The client has a temperature of 101°F (38.3°C). The client is requesting medication for pain.

The client has diminished breath sounds.

A nursing diagnosis of "Complicated Grieving" has been identified for a client whose spouse died 1 year ago. What assessment data would be appropriate evidence to justify this diagnosis? Select all that apply. The client states, "I miss my wife every day." The client keeps a picture of his wife at the bedside. The client attempted suicide 1 month ago. The client states, "I have no interest in doing anything." The client no longer indulges in his usual activities.

The client no longer indulges in his usual activities. The client attempted suicide 1 month ago. The client states, "I have no interest in doing anything."

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 requests the minister of his church to visit. The client has difficulty concentrating on the details of treatment options. The client states, "I can't handle all of this." The client reports an inability to get adequate restful sleep. The client asks for information relating to the cancer diagnosis.

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 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? The nurse has assumed that the client needs education to decrease the likelihood of repeated infection. The nurse has assumed that having a sexually transmitted infection means the client is unaware of the risks of unprotected sex. The nurse has assumed that having a sexually transmitted infection means the client is sexually promiscuous. The nurse has assumed that the client does not understand the complications of sexually transmitted infections.

The nurse has assumed that having a sexually transmitted infection means the client is sexually promiscuous.

What information provides the nurse with accuracy when developing a nursing diagnosis? a set of clinical cues specific nursing interventions a set of lab values abnormal diagnostic tests

a set of clinical cues

The nurse caring for a morbidly obese client formulates the possible nursing diagnosis, "Imbalanced Nutrition: More than Body Requirements related to excessive food intake as evidenced by morbid obesity." In order to assure the accuracy of the diagnosis, which further step must the nurse take? Validate with the client that excessive food intake is the cause of the client's obesity. Interview the client to asses the client's motivation to lose weight. Research the client's medical history to determine the client's usual weight. Determine what weight loss programs the client has utilized in the past.

Validate with the client that excessive food intake is the cause of the client's obesity.

Can a nurse develop a nursing diagnosis when there is not enough evidence to support the presence of a problem, but the nurse would like to gather more evidence? Yes, this defines a risk diagnosis. Yes, this defines a possible nursing diagnosis. No, a nursing diagnosis describes an existing problem. No, the nurse must have all of the evidence before formulating the diagnosis.

Yes, this defines a possible nursing diagnosis.

The process of nursing diagnosis carries legal implications for nurses. Which of the following legal responsibilities exists for 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 independently managing the client's kidney failure choosing interventions to resolve the client's kidney failure coordinating the treatment of the client's kidney failure

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

A nurse is using Gordon's functional health patterns as an organizing framework for client assessment. The client has significant problems related to breathing for which the nurse identifies several nursing diagnostic labels, including ineffective breathing pattern and impaired gas exchange. The nurse understands that these nursing diagnoses would be organized under which functional pattern? Nutritional-metabolic Activity-exercise Congnitive-perceptual. Coping-stress tolerance

Activity-exercise

A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues provide organization, or: categorizing. clustering. grouping. diagnosing.

clustering.

A nurse is preparing to write a nursing diagnosis for a client. Which activity would the nurse need to do first? identify the significant data validate the diagnosis cluster the cues synthesize cue clusters

identify the significant data

While caring for a client admitted with Clostridium difficile infection, the nurse notes that the client has had 3 loose bowel movements in 3 hours. What would be the most appropriate nursing diagnosis to address this health problem? Risk for Injury related to urgent need for bowel evacuation Fluid Volume Excess related to diarrhea as evidenced by 3 loose bowel movements in 3 hours Diarrhea related to infectious processes secondary to Clostridium difficile infection as evidenced by 3 loose bowel movements in 3 hours Risk for Infection Transmission related to high potential for communicability

Diarrhea related to infectious processes secondary to Clostridium difficile infection as evidenced by 3 loose bowel movements in 3 hours

After a client suffers a myocardial infarction, the nurse formulates a possible nursing diagnosis of "Powerlessness." In order to determine the accuracy of the diagnosis, what would be the nurse's most appropriate action? Determine the extent of cardiac tissue damage. Assess the client's knowledge of risk factors. Identify the client's support systems. Discuss the client's health condition with the client.

Discuss the client's health condition with the client.

Nurses use approved NANDA-I nursing Diagnoses when writing diagnoses for clients. Which diagnoses represent "Domain 1: Health Promotion" as established by NANDA-I? Sedentary Lifestyle Deficient Diversional Activity Readiness for Enhanced Coping Ineffective Self-Health Management Risk for Disuse Syndrome Impaired Environmental Interpretation Syndrome

Ineffective Self-Health Management Sedentary Lifestyle Deficient Diversional Activity

A nursing diagnosis of Ineffective Airway Clearance has been chosen by the nurse caring for a client with respiratory problems. Which assessment data would be appropriate evidence of this diagnosis? Select all that apply. Labored respirations Oxygen at 3 liters/min per nasal cannula Viral pneumonia Ineffective cough Wheezes auscultated over all lung fields

Ineffective cough Wheezes auscultated over all lung fields Labored respirations

The nurse is caring for a client with AIDS (acquired immune deficiency syndrome) who frequently misses clinic appointments. The client states that transportation to the clinic is very difficult. What would be the nurse's most appropriate diagnosis? Risk for noncompliance related to missed clinic appointments Ineffective health maintenance related to AIDS (acquired immune deficiency syndrome) Ineffective health maintenance related to transportation difficulties Risk for noncompliance related to seriousness of illness

Ineffective health maintenance related to transportation difficulties

A nurse who believes strongly that women should make their own decisions is caring for a female client from a culture where women defer decisions to their husbands. Based on the client's insistence that her husband make all decisions for her, the nurse formulates a nursing diagnosis of "Dysfunctional Family Processes." What type of nursing diagnosis error has the nurse made? The nurse needs further evidence to validate this diagnosis. The nurse is not addressing the reason the client is seeking health care. The nurse has inserted her own beliefs into the interpretation of the data. The nurse has not selected the correct nursing diagnosis to address this problem.

The nurse has inserted her own beliefs into the interpretation of the data.

A nurse sees the client grimace and documents that the client is in pain, without interviewing the client to obtain further cues. The nurse has: ineffective database. a lack of cues, or premature closure. impaired cluster interpretation. inaccurate evaluation.

a lack of cues, or premature closure.

The nurse is caring for a client who is experiencing a collaborative problem. The nurse should plan the client's care based on an understanding that this problem is characterized by: an emergent condition that requires rapid nursing response. a result of disease, trauma, treatment, or diagnostic studies. a risk or wellness human response to health problems. a convenient means for communication among team members.

a result of disease, trauma, treatment, or diagnostic studies.

The nurse recognizes that health problems that can be prevented by independent nursing interventions are called: dependent nursing diagnoses. syndrome nursing diagnoses. actual or potential nursing diagnoses. collaborative nursing diagnoses.

actual or potential nursing diagnoses.

While caring for a client recovering from a CVA (cerebrovascular accident), the nurse determines that the client would benefit from the services of physical therapy. How would the nurse plan to involve physical therapy in the client's care? by formulating a collaborative problem by formulating an actual nursing diagnosis by formulating orders for physical therapy by formulating a medical diagnosis

by formulating a collaborative problem

The nurse is examining the assessment data of a client and diagnoses a problem of impaired tissue perfusion based on the following assessment data cues: left foot cool and pale with capillary refill > 3 seconds, diminished dorsalis pedis and posterior tibial pulses, client reports cramping pain in left foot. The nurse is doing what? formulating a nursing diagnosis identifying contributing factors validating the nursing diagnosis clustering significant data cues

clustering significant data cues

The nurse is systematically gathering a clustering data to draw inference from a newly admitted client. What does the nurse determine this process will be identified as? diagnostic reasoning. analytical thinking. Evaluation prescriptive thinking.

diagnostic reasoning.

When caring for a client, the nurse identifies and analyzes data to identify nursing diagnoses and collaborative problems. Which action is a priority role of the nurse when caring for a client with collaborative problems? identifying the client's understanding of risk factors reporting trends that suggest development of complications managing an emerging problem with the help of another registered nurse resolving health issues through independent nursing measures

reporting trends that suggest development of complications The nurse should report trends that suggest development of complications to bring to notice the need for collaborative intervention for a client. Collaborative problems are physiologic complications that require both nurse- and physician-prescribed interventions. Actions that exclude members of other disciplines are not characteristic of collaborative problem management. The development of complications is a priority over assessment of the client's knowledge of risk factors, even though these must be assessed.

A nurse is developing a plan of care for a client with a chronic respiratory problem. When developing appropriate nursing diagnoses for this client, the nurse needs to keep in mind that: the interventions planned must be within the nurse's scope of practice. The signs and symptoms of the disease are part of the information conveyed. the problem's existence requires validation by the physician. the main focus is on monitoring the body's pathophysiologic response.

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

The nurse is assessing a client who was just admitted to the unit following an abdominal hysterectomy. On which assessment finding would the nurse base the priority diagnosis? Client reports being very sleepy Abdominal area soft with diminished bowel sounds throughout Diminished breath sounds in left lower lobe Dressing intact with slight bloody discharge present Skin warm and dry

Diminished breath sounds in left lower lobe Abnormal respiratory findings are a priority in the postoperative client. Slight discharge on the abdominal dressing may be expected but should be noted and observed for further bleeding. Being sleepy following anesthesia is a normal finding. Warm and dry skin is a normal finding.

A female client undergoing chemotherapy for breast cancer has lost all her 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 Disturbed Body Image as evidenced by client's refusal to look at self Disturbed Body Image related to breast cancer Disturbed Body Image as evidenced by client's negative comments

Disturbed Body Image related to loss of hair

A nurse is caring for a marathon runner who collapsed while running in extremely warm weather. Upon admission, the client's temperature is 102°F (38.9°C). What is the most appropriate nursing diagnosis? Electrolyte imbalance Hyperthermia Heat exhaustion Dehydration

Hyperthermia

Which of the following best defines nursing diagnoses? Identification of actual client problems, not including potential problems Identification of client problems that require collaboration with other health care professionals Identification of client problems that nurses can treat independently Identification of signs and symptoms that identify diseases

Identification of client problems that nurses can treat independently

Which of the following assessment findings would support the nursing diagnosis of Impaired Skin Integrity? Select all that apply. History of appendectomy Unable to turn in bed without assistance Impaired mobility due to recent stroke Up with assistance to bedside commode Uncontrolled diabetes

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

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? Asthma Attack Acute Dyspnea Ineffective Airway Clearance Bronchial Pneumonia

Ineffective Airway Clearance

A nurse is caring for a client who has pneumonia. What is an appropriate nursing diagnosis? Altered Airway Infection (Pulmonary) Ineffective Airway Clearance Impaired Respiration

Ineffective Airway Clearance Ineffective Airway Clearance is a plausible nursing diagnosis for a client with pneumonia. The other listed options are not recognized nursing diagnoses.

Which is the best example of a nursing diagnosis? Cellulitis related to infection as evidenced by warm, reddened skin. Ineffective Airway Clearance as evidenced by client not speaking. Gastroesophageal Reflux related to low stomach pH as evidenced by foul breath and burning sensation in throat. Ineffective Breastfeeding related to latching as evidenced by nonsustained suckling at the breast.

Ineffective Breastfeeding related to latching as evidenced by nonsustained suckling at the breast.

A teenager on life support after a diving accident has no brain wave activity. The parents tell the nurse that they are sure their child will wake up soon. Which nursing diagnosis would the nurse identify to assist the parents of the child? Interrupted Family Processes related to inability to accept their child's inevitable death as evidenced by the parents' statement that their child will wake soon Death Anxiety related to dysfunctional family processes as evidenced by parents' refusal to acknowledge the child's condition Death Anxiety related to anticipated death of child as evidenced by child having no brain wave activity Interrupted Family Processes related to brain death of their child as evidenced by parents' refusal to accept the inevitable

Interrupted Family Processes related to inability to accept their child's inevitable death as evidenced by the parents' statement that their child will wake soon

Which nursing diagnosis is written incorrectly as a result of the health problem and etiology being reversed? Prolonged Immobility related to impaired skin integrity AEB 1-in (2.5-cm) diameter open area on right buttocks surrounded by a 1-in (2.5-cm) margin of redness; wound surface clean and beefy red; no drainage or foul odor detected. Pain related to tissue trauma and inflammation AEB client pain rating of 8 out of 10, client guarding abdominal incision, heart rate 109, respiratory rate 28, blood pressure 132/88. Risk for Disturbed Body Image related to decreased ability to cope with surgical removal of right breast Risk for Injury related to lack of knowledge of crutch walking

Prolonged Immobility related to impaired skin integrity AEB 1-in (2.5-cm) diameter open area on right buttocks surrounded by a 1-in (2.5-cm) margin of redness; wound surface clean and beefy red; no drainage or foul odor detected. Impaired Skin Integrity related to prolonged immobility is the correct format. Prolonged immobility contributes (etiology) to impaired skin integrity (problem).

The care plan for a postoperative client includes a nursing diagnosis of "Risk for urinary retention." The nurse determines that the client has been voiding adequately. What is the nurse's most appropriate action? Continue to observe for urinary retention because of the client's postoperative status. Revise the nursing diagnosis because the client's status has changed. Initiate a collaborative problem to address the client's changing status. Consult with the physician about the revision of the nursing diagnosis.

Revise the nursing diagnosis because the client's status has changed.

An older adult client's venous ulcer has become foul-smelling after she began using strips of a sheet to dress the wound when she ran out of sterile dressing supplies. How should the nurse document a nursing diagnosis statement related to this client's circumstances? Acute Confusion related to appropriate wound care Knowledge Deficit due to risk for infection Risk for sepsis related to local infection. Risk for Infection related to knowledge deficit

Risk for Infection related to knowledge deficit

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? Impaired Comfort Risk for Suicide Disturbed Body Image Risk for Powerlessness

Risk for Powerlessness