Chapter 07: Nursing Diagnosis

Chapter 07: Nursing Diagnosis

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. The nurse completes a health and physical assessment on a patient admitted with a fractured pelvis. Which of the following tasks should the nurse do next?

a.	Analyze and cluster the assessment information.
b.	Formulate a nursing diagnosis addressing actual issues.
c.	Determine the need for potential nursing diagnoses.
d.	Create health promotion diagnoses for the patient.

 

 

ANS:  A

Nursing diagnosis is the second step of the nursing process. Formulation of nursing diagnoses follows patient data collection and involves the analysis and clustering of related assessment information. Actual nursing diagnoses identify existing problems or concerns of a patient. Risk nursing diagnoses apply when there is an increased potential or vulnerability for a patient to develop a problem or complication. Health-promotion nursing diagnoses are used in situations in which patients express interest in improving their health status through a positive change in behavior. The analysis of information is required to determine nursing diagnoses.

 

DIF:    Applying        REF:   p. 96              OBJ:   7.1                 TOP:   Implementation

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Care Coordination

 

2. A group of patients in a community center attend a nursing-led information session on the risks of contracting tuberculosis. After the presentation several patients ask the nurse for additional web-based resources regarding the lung disease. Which type of nursing diagnosis would the nurse choose for the community care plan?

a.	Risk
b.	Actual
c.	Health-promotion
d.	Potential

 

 

ANS:  C

Health-promotion nursing diagnoses are used in situations in which patients express interest in improving their health status through a positive change in behavior. Although most nursing diagnoses are used for individual patients, nursing diagnosis taxonomy can be applied to families, groups of individuals, and communities. Actual nursing diagnoses identify existing problems or concerns of a patient. Risk (potential) nursing diagnoses apply when there is an increased potential or vulnerability for a patient to develop a problem or complication.

 

DIF:    Applying        REF:   p. 96              OBJ:   7.1                 TOP:   Implementation

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Care Coordination

 

3. A nurse completes a care plan for an assigned patient diagnosed with an inflammation of the pericardium. Which diagnosis written on the plan indicates a need for further instruction on using the nursing process?

a.	Pericarditis
b.	Acute pain
c.	Risk for decreased cardiac output
d.	Activity intolerance

 

 

ANS:  A

Whereas medical diagnoses identify and label medical (physical and psychological) illnesses, nursing diagnoses are much broader in focus. Nursing diagnoses consider a patient’s response to medical diagnoses and life situations in addition to making clinical judgments based on a patient’s actual medical diagnoses and conditions. Pericarditis is a medical diagnosis defined as an inflammation of the pericardium. Pain, decreased blood flow, and intolerance to activity are a patient’s response to the medical condition of pericarditis.

 

DIF:    Analyzing      REF:   p. 97              OBJ:   7.1                 TOP:   Evaluation

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Care Coordination

 

4. North American Nursing Diagnosis Association International (NANDA-I) is an organization focusing on revising nursing diagnosis taxonomy and evaluates nursing research to validate the diagnostic labels. The NANDA-I taxonomy and new nursing diagnoses are published every:

a.	2 years.
b.	3 years.
c.	4 years.
d.	5 years.

 

 

ANS:  A

The NANDA-I taxonomy is dynamic. Every 2 years, NANDA-I members meet to focus on revision of the taxonomy and evaluation of nursing research conducted to validate current and evolving nursing diagnoses.

 

DIF:    Remembering                                 REF:   p. 97               OBJ:   7.2

TOP:   Assessment

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Care Coordination