Fundamentals 2 Exam 1 Chapter 17: Nursing Diagnosis

ANS: B
The standard formal nursing diagnosis serves several purposes. A nursing diagnosis provides the precise definition that gives all members of the health care team a common language for understanding the patient’s needs. Nursing diagnoses allow nurses to communicate what they do among themselves, with other health care professionals, and the public. Nursing diagnoses distinguish the nurse’s role from that of the physician, and help nurses focus on the scope of nursing practice while fostering the development of nursing knowledge.

ANS: B
Acute pain is the only NANDA-I–approved diagnosis listed. Sleep disorder and high blood pressure (hypertension) are medical diagnoses, and sore throat is a subjective complaint.

ANS: C
The related to factor of alveolar-capillary membrane changes is accurately written because it is a patient response to the disease process of pneumonia that the nurse can treat. The related to factors lower lobe infiltrate, dehydration, and pneumonia are all medical diagnoses that the nurse cannot change. Lower lobe infiltrate is simply another term for pneumonia, a medical diagnosis. The related to factor should be the cause of the problem (nursing diagnosis) that a nurse can address.

ANS: B
The etiology, or related to factor, of tibial fracture is a medical diagnosis and needs to be revised. The nursing diagnosis is appropriate because the patient is unable to ambulate. The patient’s chief complaint is what the patient subjectively states is the problem. No subjective data are included in the diagnostic statement. The defining characteristic (subjective and objective data that support the diagnosis) is appropriate for Impaired physical mobility.

ANS: A
Diagnostic reasoning is defined as a process of using the assessment data gathered about a patient to logically explain a clinical judgment, in this case a nursing diagnosis. Defining characteristics are assessment findings that support the nursing diagnosis. Clinical criteria are objective signs or subjective symptoms. Diagnostic labeling is simply assigning the diagnosis.

ANS: D
Based on the assessment data provided, the only supportive evidence for one of the diagnosis options is “Complains of moderate discomfort,” which would support Acute pain. No supportive evidence is provided for any of the other diagnoses. The patient may indeed develop signs or symptoms of the other problems, but supportive data are presently lacking in the provided information

ANS: A
After a thorough assessment, the nurse should proceed to analyzing the data and formulating a nursing diagnosis before proceeding with developing the plan of care and determining appropriate interventions. The evaluation phase involves determining whether the interventions were effective.

ANS: D
The patient’s desire is to increase his specific level of wellness to a higher level of wellness. An actual diagnosis describes human responses to health conditions or life processes that exist. A risk diagnosis describes human responses to health conditions/life processes that will possibly develop. A health promotion diagnosis is a clinical judgment of a patient’s motivation and desire to enhance well-being and does not require a current level of wellness.

ANS: A
The diagnostic process should flow from the assessment. Without a thorough assessment, the nurse is more apt to misdiagnose a patient’s responses, and the wrong interventions may be implemented. In this case, the nurse should have assessed the patient’s blood pressure before giving the medication. The nurse could have prevented the patient’s untoward reaction if the low blood pressure was assessed first. The nurse could have notified the physician, held the medication, or taken other steps to prevent an adverse reaction.

ANS: C
Abdominal distention, no reported bowel movement, and abdominal pain are the defining characteristics. Decreased gastrointestinal motility secondary to pain medication is an etiology or related to factor. Constipation is the identified problem derived from the defining characteristics.

ANS: B
The signs and symptoms, or defining characteristics, for the diagnosis Activity intolerance include decreased oxygen saturation when ambulating and complaints of shortness of breath when getting out of bed. The key to supporting the diagnosis of Activity intolerance is that only these two characteristics involve how the patient tolerates activity

ANS: B
Disruption of tissue integrity is a possible cause or etiology of pain. A complaint of pain, headache, and discomfort are examples of things a patient might say (subjective data or defining characteristics) that lead a nurse to select Acute pain as a nursing diagnosis.

ANS: B
The cause or related to factor in this case is the patient’s lack of oral intake due to lack of appropriate food choices. The patient’s religious preferences, race, and ethnicity did not cause his weight loss. Ultimately, the lack of food choices and his decreased intake caused him to lose weight. Weight loss is a sign of imbalanced nutrition, not a cause. The weight loss would be noticed during the assessment and would lead to the nursing diagnosis, not in reverse order.

ANS: A
Following assessment, analyzing the data and assigning a nursing diagnosis is the next step in the nursing process. Planning occurs after assigning the problem to establish goals. Nursing interventions are carried out in the implementation phase. The evaluation phase occurs after intervening to establish whether interventions have been effective in helping the patient meet his/her goals.

ANS: D
The potential diagnostic error here is an error in data collection. If a new nurse is not comfortable with his/her assessment technique, he or she should ask another nurse to validate the findings. Diagnosing before validating assessment findings leads to the potential for error. Assessment data are not sufficient to assign the diagnoses Decreased cardiac output and Decisional conflict. Every nurse needs to perform his or her own assessment. A patient’s status can change very rapidly. A nurse who copies the previous shift’s assessment is not practicing according to standards of practice and is violating the code of ethics.

ANS: A
Diagnosis should take place only after the database is completed. The data should be clustered and reviewed to see if any patterns are present before a nursing diagnosis is assigned. Risk for infection is an appropriate diagnosis for a patient with an intravenous (IV) site in place. The IV site involves a break in skin integrity and is a potential source of infection. The diagnostic process should proceed in steps. Completing the interview before the physical examination is appropriate. The patient’s cultural background and developmental stage are important to include in a patient database.

ANS: C
The signs the patient is exhibiting are consistent with dehydration. Even without knowing the clinical manifestations of dehydration, the question can be answered by the process of elimination. Adult failure to thrive, hypothermia, and nausea are not appropriate diagnoses because data are insufficient to support these diagnoses.

ANS: B
The nurse needs to first ensure that the symptoms support the diagnosis. By definition, diarrhea means that a patient is having frequent stools. Asking about irritating foods and medications may help the nurse determine the cause of the diarrhea, but first the nurse needs to make sure the diagnosis is appropriate. Asking the patient if he can make it to the bathroom will help to establish a diagnosis of incontinence, not diarrhea. The question is asking for the most appropriate statement to establish the diagnosis of Diarrhea.

ANS: A
The nurse must establish that the patient feels the urge and is unable to void. The question “Do you feel like you need to use the bathroom?” is the most appropriate to ask. This question can be answered without knowledge of the diagnosis of Urinary retention. Discussing the ability to walk to the bathroom and asking about safety rails pertain to mobility and safety issues, not to retention of urine. Taking certain medications may lead to urinary retention, but that information would establish the etiology. The question is asking for the nurse to first establish the correct diagnosis.