Diagnosing

1. 1Which of the following is a correct guideline to follow when composing a nursing diagnosis statement?

   1. APlace defining characteristics after the etiology and link them by the phrase “as evidenced by.”
   2. BPhrase the nursing diagnosis as a client need.
   3. CPlace the etiology prior to the client problem and linked by the phrase “related to.”
   4. DIncorporate subjective and judgmental terminology.
2. 2In planning the care for a client who has pneumonia, the nurse collects data and develops nursing diagnoses. Which of the following is an example of a properly developed nursing diagnosis?

   1. AIneffective airway clearance as evidenced by inability to clear secretions
   2. BIneffective health maintenance as evidenced by unhealthy habits
   3. CIneffective breathing pattern related to pneumonia
   4. DIneffective therapeutic regimen management due to smoking
3. 3The nurse has identified a number of risk nursing diagnoses in the care of an adolescent who has been admitted to the hospital for treatment of an eating disorder. These risk diagnoses indicate which of the following?

   1. AThe client is more vulnerable to certain problems than other individuals would be.
   2. BThe diagnoses present significant risks for the development of medical diagnoses.
   3. CThe data necessary to make a definitive nursing diagnosis is absent.
   4. DThe diagnosis has yet to be confirmed by another practitioner.
4. 4A client with a new colostomy often becomes short and sarcastic when nurses attempt to teach him about the management of his new appliance. The nurse has consequently documented “Noncompliance related hostility” on the client’s chart. What mistake has the nurse made when choosing and documenting this nursing diagnosis?

   1. APresuming to know the factors contributing to the problem
   2. BIdentifying a problem that cannot be changed
   3. CIdentifying a problem without corroborating evidence in the statement
   4. DNeglecting to identify potential complications related to the problem
5. 5The nurse has drafted a nursing diagnosis of Imbalanced Nutrition: More Than Body Requirements in the care of moderately obese client. How should the nurse proceed after writing this diagnosis?

   1. AValidate the nursing diagnosis
   2. BIdentify potential complications
   3. CCross-reference the nursing diagnosis with medical diagnoses
   4. DModify interventions based on the diagnosis
6. 6Which of the following provides the nurse with the most reliable basis on which to choose a nursing diagnosis?

   1. AA cluster of several significant cues of data that suggest a particular health problem
   2. BA single, definitive cue that is closely associated with a common diagnosis
   3. CA cue that can be verified by objective, medical data
   4. DA group of related nursing diagnoses that exist within the same NANDA-approved domain
7. 7In addition to identifying responses to actual or potential health problems, what is another purpose of the diagnosing step in the nursing process?

   1. ATo collect information about subjective and objective data
   2. BTo correlate nursing and medical diagnostic criteria
   3. CTo identify etiologies of health problems
   4. DTo evaluate mutually developed expected outcomes
8. 8Which of the following client care concerns is clearly a nursing responsibility?

   1. APrescribing medications
   2. BMonitoring health status changes
   3. COrdering diagnostic examinations
   4. DPerforming surgical procedures
9. 9After completing assessments, a nurse uses the data collected to identify appropriate nursing diagnoses for a client. For what are the nursing diagnoses used?

   1. ASelecting nursing interventions to meet expected outcomes
   2. BEstablishing a database of information for future comparison
   3. CMutually establishing desired outcomes of the plan of care
   4. DEvaluating the effectiveness of the established plan of care
10. 10Which of the following statements accurately describes the legal responsibility of the nurse making a diagnosis for a client?

    1. AThe nurse may make a diagnosis, but the physician is responsible for making sure it is appropriate for the client.
    2. BThe nurse practitioner is responsible for making all nursing diagnoses and determining if they are appropriate for the client.
    3. CThe nurse must decide if he or she is qualified to make a nursing diagnosis and will accept responsibility for treating it.
    4. DThe health care facility directs the nursing diagnosis in order to receive payment for services performed.

11. 11A student is reviewing a client’s chart before giving care. She notes the following diagnoses in the contents of the chart: “appendicitis” and “acute pain.” Which of the diagnoses is a medical diagnosis?

    1. ANeither appendicitis nor acute pain
    2. BBoth appendicitis and acute pain
    3. CAppendicitis
    4. DAcute pain
12. 12A nurse develops a plan of care to meet the needs of a client who has had a large loss of blood after a snowmobile crash. Intravenous fluids and blood are administered and the nurse monitors the client’s physiologic response. This action is known as a:

    1. Amedical diagnosis.
    2. Bnursing diagnosis.
    3. Ccollaborative problem.
    4. Dgoal for care.
13. 13A nurse is reviewing the health history and physical assessment findings for a client who is having respiratory problems. Of the following data collected, what data from the health history would be a cue to a nursing diagnosis for this problem?

    1. A“I often have diarrhea after I eat spicy foods.”
    2. B“My skin is so dry I just can’t keep from scratching.”
    3. C“I get out of breath when I walk a few steps.”
    4. D“I just feel so bad about myself these days.”
14. 14What is the focus of a diagnostic statement for a collaborative problem?

    1. AThe client problem
    2. BThe potential complication
    3. CThe nursing diagnosis
    4. DThe medical diagnosis
15. 15Successful implementation of each step of the nursing process requires high-level skills in critical thinking. Which of the following statements accurately describe a guideline for using this process?

    1. ATrust clinical judgment and experience over asking for help.
    2. BRespect clinical intuition, but never allow it to determine a diagnosis.
    3. CRecognize personal biases as a strength in formulating diagnoses.
    4. DKeep an open mind and trust your intuition when formulating diagnoses.
16. 16A nurse observes a new mother tenderly holding and softly talking to her baby. What does this observation tell the nurse about the baby’s strengths?

    1. ANothing; this observation is not important.
    2. BThe mother is just behaving as all mothers do.
    3. CA baby is not capable of having strengths.
    4. DNurturing is a strength for developing infants.
17. 17A nurse completes a health history and physical assessment for an adolescent before he begins football practice. Based on findings, the nurse recommends reinforcing good health habits. What conclusion did the nurse reach after interpreting and analyzing the data?

    1. ANo problem
    2. BPossible problem
    3. CActual problem
    4. DClinical problem
18. 18A nurse caring for an older adult client in a long-term care facility notices that the bedding is wet when the client gets up in the morning. The nurse collects more data to form a conclusion. What type of problem is involved in this scenario?

    1. ANo problem
    2. BPossible problem
    3. CActual problem
    4. DClinical problem
19. 19A nurse is formulating a nursing diagnosis for a client with a respiratory disease. Which of the following would be correct?

    1. A“needs nasal oxygen to improve breathing”
    2. B“cough related to ineffective airway clearance”
    3. C“ineffective airway clearance related to thick mucus”
    4. D“refuses to cough and expectorate thick mucus”
20. 20A nurse writes the following nursing diagnosis for a client with Alzheimer’s disease: Disturbed Thought Processes related to Alzheimer’s disease as evidenced by incoherent language. Which part of this diagnosis is considered the problem statement?

    1. Adisturbed thought processes
    2. Brelated to
    3. CAlzheimer’s disease
    4. Dincoherent language
21. 21A nurse is formulating a diagnosis for a client who is reliving a brutal mugging that took place several months ago. The client is crying uncontrollably and states that he “can’t live with this fear.” Which of the following diagnoses for this client is correctly written?

    1. APost-trauma syndrome related to being attacked
    2. BPsychological overreaction related to being attacked
    3. CNeeds assistance coping with attack
    4. DMental distress related to being attacked
22. 22Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics?

    1. ARisk nursing diagnosis
    2. BActual nursing diagnosis
    3. CPossible nursing diagnosis
    4. DWellness diagnosis
23. 23A nursing diagnosis is written as Disturbed Self-Esteem related to presence of large scar over left side of face. What does the phrase “Disturbed Self-Esteem” identify?

    1. AThe expected outcome of the plan of care
    2. BA cue to determining a health problem
    3. CThe major defining characteristic of a health problem
    4. DThe health state or problem of the client
24. 24In the nursing diagnosis Disturbed Self-Esteem related to presence of large scar over left side of face, what part of the nursing diagnosis is “presence of large scar over left side of face”?

    1. AEtiology
    2. BProblem
    3. CDefining characteristics
    4. DClient need
25. 25A student identifies Fatigue as a health problem and nursing diagnosis for a client receiving home care for treatment of metastatic cancer. What statement or question would be best to validate this client problem?

    1. A“I have assessed you and find you are fatigued.”
    2. B“I analyzed and interpreted your information as fatigue.”
    3. C“Why are you so tired all the time?”
    4. D“I think fatigue is a problem for you. Do you agree?”
26. 26Of all the benefits of using nursing diagnoses, which one is probably the most important to nurses?

    1. ADefining the domain of nursing practice
    2. BInforming patients of their care
    3. CImproving communication among nurses
    4. DStructuring curricular content
27. 27According to Maslow’s hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure?

    1. AIneffective airway clearance
    2. BIneffective coping
    3. CImpaired urinary elimination
    4. DRisk for body image disturbance
28. 28A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling makes his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client’s concern?

    1. AImpaired physical mobility
    2. BDisturbed body image
    3. CRisk for infection
    4. DRisk for social isolation
29. 29A client who has to undergo a parathyroidectomy is worried that he may have to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan?

    1. ARisk for impaired physical mobility due to surgery
    2. BIneffective denial related to poor coping mechanisms
    3. CDisturbed body image related to the incision scar
    4. DRisk of injury related to surgical outcomes
30. 30A nurse who is caring for an unresponsive client formulates the nursing diagnosis, “Risk for Aspiration related to reduced level of consciousness.” The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis?

    1. AIs written as a two-part statement
    2. BDescribes human response to a health problem
    3. CDescribes potential for enhancement to a higher state
    4. DMade when not enough evidence supports the problem
31. 31After assessing a client, the nurse formulates several nursing diagnoses. Which of the following would the nurse identify as an actual nursing diagnosis?

    1. AImpaired urinary elimination
    2. BReadiness for enhanced sleep
    3. CRisk for infection
    4. DPossible impaired adjustment
32. 32What is the nurse accountable for, according to the state nurse practice act?

    1. AContinuing education
    2. BNursing diagnoses
    3. CPrescribing medications
    4. DMentoring other nurses
33. 33A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues provide organization or …

    1. ACategorizing
    2. BDiagnosing
    3. CGrouping
    4. DClustering
34. 34The nurse is providing care for a client who experienced an ischemic stroke five days ago. Which of the following diagnoses would the nurse be justified in identifying and documenting in the care of this client? Select all that apply.

    1. ADysphagia
    2. BBowel Incontinence
    3. CImpaired Swallowing
    4. DImpaired Physical Mobility
    5. ERisk for Hemiparesis
35. 35Which of the following reflects the diagnosis phase?

    1. AThe nurse identifies that the client does not tolerate activity.
    2. BThe nurse performs wound care using sterile technique.
    3. CThe nurse sets a tolerable pain rating with the client.
    4. DThe nurse documents the client’s response to pain medication.

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Test 1 Quiz on Diagnosing, created by Chris Tatam on 03/02/2019.

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Chris Tatam

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