Fundamentals Nursing Prep U Chapter 12 Diagnosing
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
A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination?
Bowel Incontinence
A pregnant client asks the nurse for information on breastfeeding her baby. What type of nursing diagnosis would the nurse formulate?
A wellness diagnosis
The care plan for a client who has been frequently admitted to the hospital for exacerbation of COPD (chronic obstructive pulmonary disease) has a nursing diagnosis of "Noncompliance related to lack of knowledge as evidenced by frequent admissions to the hospital." What is the most appropriate method for the nurse to use to validate the nursing diagnosis?
Assess the client's knowledge of COPD.
While developing a plan of care for a client, what should the nurse do before selecting a nursing diagnosis?
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?
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.
What does the nursing diagnosis represent?
Cues
Which of the following is classified as a nursing diagnosis?
Grieving
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
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 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?
Human responses to actual or potential health problems
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
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
A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain that is interfering with her ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records?
Impaired physical mobility related to pain
A client is brought to the emergency room in respiratory arrest and immediately intubated and placed on mechanical ventilation. What is the most appropriate nursing diagnosis for this client?
Impaired spontaneous ventilation
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 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
The formulation of nursing diagnoses is unique to the nursing profession. Which statement accurately represents a characteristic of diagnosing?
Nurses write nursing diagnoses to describe client problems that nurses can treat.
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?
Ineffective health maintenance related to transportation difficulties
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
An older adult client recently admitted to a long term care facility expresses anger and depression about the relocation. The client consumes very little food and is losing weight. What nursing diagnosis would be most appropriate for the nurse to select in order to plan this client's care?
Relocation Stress Syndrome
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 diminished breath sounds.
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 having a sexually transmitted infection means the client is sexually promiscuous.
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 has inserted her own beliefs into the interpretation of the data.
When reviewing the client's history, the nurse notes that it has been recorded that the client's last 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.
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.
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
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 possible nursing diagnosis.
A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues provide organization, or:
clustering
The nursing diagnosis taxonomy provides nursing with:
common language
The act of analyzing and synthesizing cues requires:
critical thinking
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
What is the nurse accountable for, according to state nurse practice acts?
making nursing diagnoses
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?
reporting trends that suggest development of complications
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.
A nurse is applying the nursing process and is in the diagnosis phase. With which activities would the nurse be involved? Select all that apply.
• Analyzing data • Identifying patterns • Identifying indicators of potential dysfunction
The nurse is providing care for a client who experienced an ischemic stroke 5 days ago. The client now has difficulty swallowing liquids solids, weakness on the right side of the body and incontinent of bowel and bladder. Which priority nursing diagnoses would the nurse identify and document in the care of this client? Select all that apply.
• Bowel Incontinence • Impaired Swallowing • Impaired Physical Mobility
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 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 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."
