Chapter 17: nursing diagnosis

A nurse adds a nursing diagnosis to pt care plan. Which information did the nurse document? A) decreased cardiac output related to altered myocardial contractilty B) Patient needs a low-fat diet related to inadequate heart perfusion. C) Offer a low-fat diet because of heart problems. D) Acute heart pain related to discomfort.

A

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? A) " do you feel like you need to go to the bathroom?" B) "Are you able to walk to the bathroom by yourself?" C) "When was the last time you took your medicine?" D) "Do you have a safety rail in your bathroom at home?"

A

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. A) 1, 3, 4, 2, 5 B) 3. 4. 5.2 C) 4,3,3,2 D) 4, 3, 2, 5

A

The nurse is reviewing a pt plan , impaired physical mobility related to tibial fracture as evidenced by pt inability to ambulate. Which part of the diagnostic statement does the nurse need to revise? A) Etiology B) Nursing diagnosis C) Collaborative problem D) defining characteristics

A

The nurse is reviewing patient database for significant changes and discover that the pt has not voided in 8 hours. The pt kidney function lab results are abnormal & the pt oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review? A) Diagnosis B) Planning C) Implementation D) Evaluation

A

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 new nurse writes the following nursing diagnoses on a patient's care plan. Which nursing diagnosis will cause the nurse manager to intervene? A) Hemorrhage B) Wandering C) Urinary retention D) Impaired swallowing

B

After accessing a pt a nurse develops a standard formal nursing diagnosis bry formal nursing diagnosis. What is the rationale for the nurse's actions? A) to form a language that can be encoded only by nurses B) to distinguish the nurse role from the physicians role C) To develop clinical judgement based on the others institution D) to help nurses focus on the scope of medical practice

B

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? A) decreased oral intake and decreased oxygen saturation when ambulating B) decreased oxygen saturation when ambulating and reports of short was of breath

B

Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved? A) sore throat B) acute pain C) sleep apnea D) heart failure

B

Which question would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea? A) "What types of foods do you think caused your upset stomach?" B) "How many bowel movements a day have you had?" C) "Are you able to get to the bathroom in time?" D) "What medications are you currently taking?"

B

A charge ming i came new die pis of te life in or prese the charge use to follow up? A) Assigning a documented nursing diagnosis of risk for infection for a pt on intravenous (IV) antibiotics B) Completing an interview and physical examination before adding a nursing diagnosis C) Developing a nursing diagnoses before completing the database D) including cultural and religious preferences in the database

C

A nurse adds the following diagnosis to a patient's care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidencea by the patient reporting no bowel movement in seven days, abdominat astention, and abdominal pain. Which element did the nurse write as the defining characteristic? A. Decreased gastrointestinal motility B. Pain medication C. Abdominal distention D. Constipation

C

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? A) Assigning clinical cues B) Defining characteristics C) Diagnostic reasoning D) Diagnostic labeling

C

A nurse performs an assessment on patient . Which assessment data will the nurse use as an etiology for acute pain? A) discomfort while changing position B) report pain as 7 C) disruption of tissue integrity D) dull headache

C

A palien present to the mergeney deparine following a motor vehide crash that causes right femur fracture .The leg is discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care? A) Posttrauma syndrome B) constipation C) acute pain D) anxiety

C

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? A)Adult failure to thrive B)Hypothermia C) Deficient fluid volume D) Nausea

C

A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to the patient's care plan? A) Infection B) Risk for infection C) Impaired skin integrity D) Staphylococcal leg infection

C

A pt with spinal cord injury is seeking to enhance urinary elimination abilities by learning self cauterization versus assisted cauterization 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? A) risk B) problem focuses C) health promotion D) collaborative problem

C

A nurse is developing nursing diagnoses for a group of patients. Which nursing diagnoses will the nurse use? (Select all that apply.) A) Anxiety related to barium enema B) Impaired gas exchange related to asthma C) Impaired physical mobility related to incisional pain D) Nausea related to adverse effect of cancer medication E) Risk for falls related to nursing assistive personnel leaving bedrail down

C, D

A nurse develops a nursing diagnostic statement for a patient with medical diagnosis of pneumonia with chest x rays result for lower lobe infiltrates. Which nursing diagnosis did the nurse write? A) Ineffective breathing pattern related to pneumonia B) Risk for infection related to chest x-ray procedure C) Risk for deficient fluid volume related to dehydration D) Impaired gas exchange related to alveolar-capillary membrane changes

D