Exam Chapter 4

The nurse identifies a collaborative problem for a client. What should the nurse recall when creating the nursing diagnosis statement for this client problem? Select all that apply. 1) The problem should be a potential problem. 2) The disease, test, or treatment is the etiology. 3) The etiology can be treated with independent nursing interventions. 4) The focus for the interventions is to monitor and prevent complications. 5) The second part of the statement is the problem that is being monitored

. 1) The problem should be a potential problem. 2) The disease, test, or treatment is the etiology. 4) The focus for the interventions is to monitor and prevent complications. 5) The second part of the statement is the problem that is being monitored

The preceptor reviews collaborative problems with a new graduate. Which statement should the preceptor use to describe this type of client problem? 1) A collaborative problem is always a potential problem. 2) A collaborative problem cannot be monitored or controlled. 3) A collaborative problem is unrelated to a medical diagnosis. 4) A collaborative problem can be prevented by an individual nursing intervention

1) A collaborative problem is always a potential problem.

The nurse is writing a nursing diagnosis for a client. Which part of the statement indicates the interventions required to address the problem? 1) Etiology 2) Problem 3) Frequency 4) Completion date

1) Etiology

The patient verbalizes an overwhelming lack of energy, stating, "I still feel exhausted even after I sleep. I feel guilty when I can't keep up with my usual daily activities or sleep during the day. I've been a little depressed lately, too." The patient seems to have difficulty concentrating but has no apparent physical problems. Which diagnosis best describes his health status? 1) Fatigue related to depression 2) Fatigue related to difficulty concentrating 3) Guilt related to lack of energy 4) Chronic confusion related to lack of energy

1) Fatigue related to depression

Which is the primary reason for the use of a diagnostic label, or patient problem? 1) It is used to develop client goals. 2) It is used to develop cue clusters. 3) It is used to develop interventions. 4) It is the etiology.

1) It is used to develop client goals.

The nurse includes a diagnostic statement in the client's plan of care, stating, "Impaired Physical Mobility related to laziness and not having appropriate shoes." What is wrong with the diagnostic statement? 1) Judgmental 2) Too complex 3) Legally questionable 4) Without supportive data

1) Judgmental

Which nursing diagnosis is written in correct format? 1) Readiness for Enhanced Nutrition 2) Pain related to stating, "On a scale of 1 to 5, it's a 5." 3) Impaired Mobility related to pain A.M.B. hip fracture 4) Risk for Infection related to compromised immunity A.M.B. fever

1) Readiness for Enhanced Nutrition

Which is an example of a cluster of related cues? 1) Reports nausea and stomach pain after eating 2) Has a productive cough and states stools are loose 3) Has a daily bowel movement and eats a high-fiber diet 4) Respiratory rate 20 breaths/min, heart rate 85 beats/min, blood pressure 136/84

1) Reports nausea and stomach pain after eating

When creating nursing diagnoses for a client, the nurse spends considerable time on identifying the etiology. Which category of etiology should the nurse consider when writing nursing diagnoses? Select all that apply. 1) Social 2) Economic 3) Situational 4) Treatment related 5) Pathophysiological

1) Social 3) Situational 4) Treatment related 5) Pathophysiological

The nurse identifies diagnoses appropriate for a client's care. What should the nurse recall when identifying the goals for this client? Select all that apply. 1) The goals guide the assessments to complete. 2) The goal is the opposite of the unhealthy response. 3) Goals and assessments are guided by interventions. 4) The problem is the health status that needs to be changed. 5) The problem determines the outcomes to measure change.

1) The goals guide the assessments to complete. 2) The goal is the opposite of the unhealthy response. 4) The problem is the health status that needs to be changed. 5) The problem determines the outcomes to measure change.

Which is a criticism of standardized nursing diagnoses developed by NANDA-I? 1) There is little research to support nursing diagnoses labels. 2) A perfect nursing diagnosis must be written for it to be useful. 3) They are not included in all states' nurse practice acts. 4) Other professions do not recognize nursing diagnoses.

1) There is little research to support nursing diagnoses labels

The nurse is developing a diagnostic statement when planning care for a client. The statement reads: Possible Risk for Constipation related to irregular defecation habits Patient states that "When I'm busy, I can't always take the time to go to the bathroom." What is wrong with the format of this diagnostic statement? 1) Possible nursing diagnoses do not have signs and symptoms. 2) A nursing diagnosis is either a possible risk or a risk, not both. 3) Constipation is a medical diagnosis. 4) The etiology is actually a defining characteristic.

2) A nursing diagnosis is either a possible risk or a risk, not both.

How does a risk nursing diagnosis differ from a possible nursing diagnosis? 1) A risk diagnosis is based on data about the patient. 2) A possible diagnosis is based on partial (or incomplete) data. 3) Nurses collect the data to support risk diagnoses. 4) A possible diagnosis becomes an actual diagnosis when symptoms develop.

2) A possible diagnosis is based on partial (or incomplete) data.

Which is an example of a problem that nurses can treat independently? 1) Hemorrhage 2) Nausea 3) Fracture 4) Infection

2) Nausea

The nurse identifies a collaborative problem for a client. Which type of interventions should be selected to address this problem? Select all that apply. 1) Client requested 2) Nursing prescribed 3) Physician prescribed 4) Pharmacist prescribed 5) Risk management suggested

2) Nursing prescribed 3) Physician prescribed

Based only on Maslow's hierarchy of needs, which nursing diagnosis should have the highest priority? 1) Self-care Deficit 2) Risk for Aspiration 3) Impaired Physical Mobility 4) Disturbed Sensory Perception

2) Risk for Aspiration

Which are examples of cues? Select all that apply. 1) Taking a brisk walk five times a week 2) Using laxatives to have a bowel movement 3) Needing more sleep than usual 4) Decreasing the amount of fat in the diet 5) Weighing less than indicated by developmental norms

2) Using laxatives to have a bowel movement 3) Needing more sleep than usual 5) Weighing less than indicated by developmental norms

The patient shows the necessary defining characteristics, and the nurse diagnoses Decisional Conflict related to unclear personal values and beliefs. Which essential action should the nurse take to help ensure the accuracy of this diagnosis? 1) Ask a more experienced nurse to confirm it. 2) Have a social worker interview the patient. 3) Ask the patient to confirm the diagnosis. 4) Read about Decisional Conflict in the NANDA-I handbook.

3) Ask the patient to confirm the diagnosis.

A nursing student is having difficulty understanding the role of nursing diagnosis and setting client goals. What should the instructor explain to this student? 1) Client goals are used to coordinate care activities. 2) Client goals ensure cost-effective care is provided. 3) Diagnosis is the basis for planning client-centered goals. 4) Diagnosis ensures the correct treatment is prescribed for the client.

3) Diagnosis is the basis for planning client-centered goals.

Which is the best approach to validate a clinical inference? 1) Have another nurse evaluate it. 2) Have the physician evaluate it. 3) Have sufficient supportive data. 4) Have the client's family confirm it.

3) Have sufficient supportive data.

Which nursing diagnosis is written in the correct format when using the NANDA-I taxonomy? 1) Bowel Obstruction related to recent abdominal surgery A.M.B. nausea, vomiting, and abdominal pain 2) Inability to Ingest Food related to imbalanced nutrition: less than body requirements A.M.B. inadequate food intake, weight less than 20% under ideal body weight 3) Impaired Skin Integrity related to physical immobility A.M.B. skin tear over sacral area 4) Caregiver Role Strain related to alienation from family and friends A.M.B. 24-hour care responsibilities

3) Impaired Skin Integrity related to physical immobility A.M.B. skin tear over sacral area

Which nursing diagnosis is written in the correct format? 1) Imbalanced Nutrition: Less than Body Requirements related to body weight less than 20% under ideal weight 2) Ineffective Airway Clearance related to increased respiratory rate and irregular rhythm 3) Impaired Swallowing related to absent gag reflex 4) Excess Fluid Volume related to 3 lb weight gain in 24 hours

3) Impaired Swallowing related to absent gag reflex

Which explains why it is important to have the correct etiology for a nursing diagnosis? 1) It is the cause of the problem. 2) It cannot always be observed. 3) It directs nursing care. 4) It is an inference.

3) It directs nursing care.

Which most accurately describes nursing diagnoses? 1) They support the nurse's diagnostic reasoning. 2) They support the client's medical diagnosis. 3) They identify a client's response to a health problem. 4) They identify a client's health problem.

3) They identify a client's response to a health problem.

Which describes the difference between a collaborative problem and a medical diagnosis? 1) A collaborative problem is treated by the nurse; a physician is responsible for the treatment of a medical problem. 2) A collaborative problem is a nursing diagnosis that requires specific orders from a physician; a medical diagnosis directs all nursing care. 3) A collaborative problem has the potential to become an actual nursing diagnosis; a medical diagnosis rarely changes. 4) A collaborative problem requires intervention by the nurse and physician or other professional; a medical diagnosis requires intervention by a physician.

4) A collaborative problem requires intervention by the nurse and physician or other professional; a medical diagnosis requires intervention by a physician.

When making a diagnosis using NANDA-I, which provides support for the diagnostic label chosen by the nurse? 1) Etiology 2) Related factors 3) Diagnostic label 4) Defining characteristics

4) Defining characteristics

Which describes the most important use of nursing diagnosis? 1) Differentiates the nurse's role from that of the physician 2) Identifies a body of knowledge unique to nursing 3) Helps nursing develop a more professional image 4) Describes the client's needs for nursing care

4) Describes the client's needs for nursing care

The client's weight is appropriate for height. Laboratory values and other assessments reflect normal nutritional status. However, the client tells the nurse, "I probably eat a little too much red meat. And what is this I hear about needing omega 3 oils in my diet? I don't like to take supplements, and I think I could really improve my nutrition." Which nursing diagnoses should the nurse use when planning this client's care? 1) Balanced Nutrition 2) Possible Imbalanced Nutrition: Less Than Body Requirements 3) Risk for Imbalanced Nutrition: Less Than Body Requirements 4) Readiness for Enhanced Nutrition

4) Readiness for Enhanced Nutrition

Using Maslow's hierarchy of needs, rank the following nursing diagnoses in order of importance, beginning with the highest-priority diagnosis (1-4). (Enter the number of each step in the proper sequence, using comma and space format, such as: 1, 2, 3, 4.) 1. Anxiety 2. Risk for infection 3. Disturbed body image 4. Sleep deprivation

4,2,1,3