Prep U Chapter 15: Diagnosing

"Acute Pain related to instillation of peritoneal dialysate as evidenced by client wincing and grimacing during procedure, client description of experience as 'stabbing'" is an example of which type of nursing diagnosis? a. Actual nursing diagnosis b. Risk nursing diagnosis c. Health promotion nursing diagnosis d. Potential nursing diagnosis

a. Actual nursing diagnosis

Which describes the best approach for the development of nursing diagnoses? a. Develop nursing diagnoses from clusters of significant data. b. Develop each nursing diagnosis based on a single cue. c. Collaborate with the multidisciplinary team in the formation of nursing diagnoses. d. Collaborate with the physician in the formation of nursing diagnoses.

a. Develop nursing diagnoses from clusters of significant data.

A staff nurse comments to the charge nurse that it is unnecessary to know how to formulate nursing diagnoses because the computerized documentation system generates them automatically. What is the most appropriate response by the charge nurse? a. "A nurse is still responsible for using critical thinking to determine the validity of the nursing diagnoses generated." b. "Computerized documentation systems have eliminated the need for nurses to worry about nursing diagnoses." c. "Using computerized documentation systems allows for the standardization of client care." d. "The use of nursing diagnoses generated by a computerized documentation system is not responsible nursing practice."

a. "A nurse is still responsible for using critical thinking to determine the validity of the nursing diagnoses generated."

A client has been admitted with symptoms of shortness of breath on exertion, edematous lower extremities, extreme fatigue, and hypertension. Which are priority nursing diagnoses? Select all that apply. a. Excess Fluid Volume b. Decreased Cardiac Output c. Activity Intolerance d. Hypertension e. Congestive Heart Failure

a. Excess Fluid Volume b. Decreased Cardiac Output c. Activity Intolerance

The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping? a. Health promotion nursing diagnosis b. Actual nursing diagnosis c. Risk nursing diagnosis d. Syndrome nursing diagnosis

a. Health promotion nursing diagnosis

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? a. Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis b. Disturbed Self-Concept related to pancreatic cancer diagnosis c. Ineffective Health Maintenance related to being overwhelmed by cancer diagnosis d. Knowledge Deficit: Cancer treatment options related to new diagnosis

a. Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis

The nurse is assessing a 3-week-old infant who has not gained weight since birth. The infant's bowel sounds are present in all quadrants and breath sounds are clear to auscultation. The infant's mother reports that the child cries much of the night but sleeps better in the daytime. The mother reports that the child only breastfeeds about four times in a 24-hour period and that the mother doesn't seem to have much milk. Which nursing diagnosis would be of highest priority for this client? a. Ineffective Breastfeeding b. Disturbed Sleep Pattern c. Impaired Comfort d. Risk for Impaired Parenting e. Readiness for Enhanced Parenting

a. Ineffective Breastfeeding

The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action? a. Notify the physician for additional orders. b. Document the client's level of consciousness. c. Consult with another nurse to validate the assessment. d. Decrease stimulation and allow the client to rest.

a. Notify the physician for additional orders.

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? a. Readiness for Enhanced Knowledge: Childhood Immunizations b. Ineffective Health Maintenance related to lack of knowledge of childhood immunizations c. Risk for Infection Transmission related to lack of immunizations d. Risk for Complications related to childhood illnesses

a. Readiness for Enhanced Knowledge: Childhood Immunizations

Which is a legal responsibility of a nurse who has documented a nursing diagnosis related to a client's kidney failure? a. Reporting signs and symptoms related to the client's kidney failure b. Independently managing the client's kidney failure c. Coordinating the treatment of the client's kidney failure d. Choosing interventions to resolve the client's kidney failure

a. Reporting signs and symptoms related to the client's kidney failure

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

a. The client reports an inability to get adequate restful sleep. b. The client has difficulty concentrating on the details of treatment options. c. The client states, "I can't handle all of this."

Which factor is most likely to contribute to the nurse making a diagnostic error? a. The client withholds information during the client assessment. b. The client's subjective and objective data are congruent. c. The subjective and objective data point to a specific health issue. d. The client expands on information previously provided.

a. The client withholds information during the client assessment.

What is the purpose of establishing a nursing diagnosis? a. To describe a functional health problem b. To collaborate with the physician c. To identify medical problems d. To meet accreditation criteria

a. To describe a functional health problem

When used in a nursing diagnosis, the descriptor "impaired" has which meaning? a. Weakened or damaged b. Consisting of many interconnecting parts or elements c. Late, slow, or postponed d. Lack of proportion or relation between corresponding things

a. Weakened or damaged

A nurse, who is caring for a client admitted to the patient care unit with acute abdominal pain, formulates the care plan for the client. Which nursing diagnosis is the priority for this client? a. Impaired Comfort b. Disturbed Body Image c. Disturbed Sleep Pattern d. Activity Intolerance

a. impaired comfort

When developing an appropriate nursing diagnosis, the nurse needs to keep in mind that: a. the interventions planned must be within the nurse's scope of practice. b. the problem's existence requires validation by the physician. c. the main focus is on monitoring the body's pathophysiologic response. d. the signs and symptoms of the disease are part of the information conveyed.

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

Which component of a nursing diagnosis gives additional meaning to the nursing diagnosis? a. Composition b. Descriptors c. Dysfunction d. Qualifications

b. Descriptors

A nurse documents the following nursing diagnosis on a client's plan of care: "Fluid Volume Deficit related to gastrointestinal upset from food poisoning as evidenced by vomiting and diarrhea for the past three days, slow skin turgor, and weight loss." The nurse identifies which part of the statement as the etiology? a. Fluid volume deficit b. Gastrointestinal upset from food poisoning c. Slow skin turgor d. Vomiting

b. Gastrointestinal upset from food poisoning

When developing nursing diagnoses, the nurse should focus on which area? a. Actions to be initiated for treatment b. Human responses to actual or potential health problems c. Pathophysiological responses occurring in body systems d. Problem validation through physician collaboration

b. Human responses to actual or potential health problems

Which are accurate guidelines when formulating nursing diagnoses? Select all that apply. a. Include the medical diagnosis in the nursing diagnosis. b. Make sure the client problem precedes the etiology. c. Write the diagnosis in legally advisable terms. d. Phrase the nursing diagnosis as a client need rather than an alteration. e. Be sure the problem statement indicates what is unhealthy about the client. f. Make sure defining characteristics follow the etiology.

b. Make sure the client problem precedes the etiology. c. Write the diagnosis in legally advisable terms. e. Be sure the problem statement indicates what is unhealthy about the client. f. Make sure defining characteristics follow the etiology.

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? a. Health promotion b. Actual c. Risk d. Possible

b. actual

A nurse documents the following nursing diagnosis on a client's plan of care: "Readiness for Enhanced Breast-Feeding." The nurse has identified which type of nursing diagnosis? a. Problem-focused b. Risk c. Health promotion d. Syndrome

c. Health promotion

A client with HIV has been admitted to a health care facility. Which nursing diagnosis should be the priority, keeping in mind the client's condition? a. Risk for Activity Intolerance b. Risk for Ineffective Coping c. Risk for Infection d. Risk for Imbalanced Nutrition

c. Risk for Infection

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

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

A client diagnosed with advanced lung cancer has a nursing diagnosis of Ineffective Coping. What assessment data would provide evidence to the nurse for this diagnosis? a. The client asks about hospice services. b. The client makes funeral plans. c. The client states, "I am sure the doctors have misdiagnosed me." d. The client states, "I hope that I am able to attend my daughter's wedding."

c. The client states, "I am sure the doctors have misdiagnosed me."

When reviewing the client's history, the nurse notes that the client's last documented bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "Constipation," what assessment must the nurse make? a. The nurse should assess the client's dietary habits. b.The nurse should assess the client's bowel sounds. c. The nurse should determine the client's normal bowel elimination pattern. d. The nurse should determine the standard bowel elimination pattern for the client's age.

c. The nurse should determine the client's normal bowel elimination pattern.

During a home health care visit, the nurse identifies a nursing diagnosis of Caregiver Role Strain for a parent who is caring for a child dependent on a ventilator. What subjective assessment data would support the nurse's diagnosis? a. The parent states, "I make sure that I get regular exercise." b. The parent states, "A member of my church gives me a break twice a week." c. The parent states, "I cannot allow anyone else to help because they won't do it right." d. The parent states, "I attend support group meetings when I am able to go."

c. The parent states, "I cannot allow anyone else to help because they won't do it right."

Assessment of a client with difficulty breathing reveals that the client has thick, tenacious secretions in the trachea and bronchi and excessive sputum with coughing. The respiratory rate is slightly increased. When developing this client's plan of care, which intervention would the nurse include? a. Assisted ambulation b. Limit fluids to 1,000 ml per day c. Tracheobronchial suctioning d. Mechanical ventilation

c. Tracheobronchial suctioning

Which example of client care is not the responsibility of the nurse? a. Monitoring for changes in health status b. Promoting safety and preventing harm; detecting and controlling risks c. Tailoring treatment and medication regimens for each individual d. Confirming a medical diagnosis

d. Confirming a medical diagnosis

What association meets every 2 years to further progress in defining, classifying, and describing nursing diagnoses? a. The Canadian Nurses Association (CNA) b. The Canadian Medical Association (CMA) c. The National League for Nursing (NLN) d. NANDA-International (NANDA-I)

d. NANDA-International (NANDA-I)

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

d. Risk for Falls related to altered mobility

Which statement appropriately identifies a risk nursing diagnosis for a client who is confined to bed? a. Ineffective Airway Clearance related to bed rest b. Immobility related to confinement to bed c. Potential for Pneumonia related to inactivity d. Risk for Impaired Skin Integrity related to bed rest

d. Risk for Impaired Skin Integrity related to bed rest