Fundamentals Of Nursing 3rd ed by Wilkinson Treas - Smith
Fundamentals Of Nursing 3rd ed by Wilkinson Treas - Smith
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Chapter 4. Nursing Process: Diagnosis
Complete Chapter Questions With Answers
Sample Questions Are Posted Below
MULTIPLE CHOICE
| a) | Hemorrhage |
| b) | Nausea |
| c) | Fracture |
| d) | Infection |
ANS:Â B
A nursing diagnosis (or nursing problem) is a human response to a disease, injury, or other stressor that nurses can identify, prevent, or treat independently. Nausea is the only problem that meets that criterion; all others are medical or collaborative problems.
Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: PHSI
Cognitive Level: Application
PTS:Â Â 1
| a) | Complains of nausea and stomach pain after eating |
| b) | Has a productive cough and states stools are loose |
| c) | Has a daily bowel movement and eats a high-fiber diet |
| d) | Respiratory rate 20 breaths/min, heart rate 85 beats/min, blood pressure 136/84 mm Hg |
ANS:Â A
A cue is an unhealthy response; a cluster of cues consists of cues related to each other, such as nausea and stomach pain after eating. Productive cough and loose stools are abnormal findings but are not obviously or usually related to each other. Daily bowel movement and high-fiber diet are related but normal responses. The vital signs are also within normal limits.
Difficulty: Difficult
Nursing Process: Diagnosis
Client Need: PHSI
Cognitive Level: Analysis
PTS:Â Â 1
| a) | A risk diagnosis is based on data about the patient. |
| b) | A possible diagnosis is based on partial (or incomplete) data. |
| c) | Nurses collect the data to support risk diagnoses. |
| d) | A possible diagnosis becomes an actual diagnosis when symptoms develop. |
ANS:Â B
A possible nursing diagnosis is based on nursing knowledge, intuition, and experience and does not have enough data to support it; it is based on incomplete data. A risk diagnosis describes a problem that may develop in a vulnerable client if nursing care is not initiated to prevent it; it is made when risk factors are present in the data. Nurses collect data to support both risk and possible diagnoses; therefore, this statement does not differentiate them. A risk diagnosis becomes an actual diagnosis when symptoms develop.
Difficulty: Difficult
Nursing Process: Diagnosis
Client Need: Safe and Effective Nursing Care
Cognitive Level: Analysis
PTS:Â Â 1
| a) | A collaborative problem is treated by the nurse; a physician is responsible for the treatment of a medical problem. |
| b) | A collaborative problem is a nursing diagnosis that requires specific orders from a physician; a medical diagnosis directs all nursing care. |
| c) | A collaborative problem has the potential to become an actual nursing diagnosis; a medical diagnosis rarely changes. |
| d) | A collaborative problem requires intervention by the nurse and physician or other professional; a medical diagnosis requires intervention by a physician. |
ANS:Â D
Collaborative problems are physiological complications for which a client may be at risk based on her medical diagnosis, medical treatment, or diagnostic studies. A collaborative problem requires monitoring by the nurse and intervention by a physician. A medical diagnosis requires interventions (medications, treatments) by the physician. Medical diagnoses do not direct all nursing care. Collaborative problems have the potential to become medical, not nursing, diagnoses.
Difficulty: Difficult
Nursing Process: Diagnosis
Client Need: Safe and Effective Nursing Care
Cognitive Level: Analysis
PTS:Â Â 1
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