Chapter 4. Nursing Process: Diagnosis

Chapter 4. Nursing Process: Diagnosis

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.         Which of the following is an example of a problem that nurses can treat independently?

1)

Hemorrhage

2)

Nausea

3)

Fracture

4)

Infection

 

ANS:   2

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.

 

PTS:    1          DIF:    Moderate         REF:    pp. 57

KEY:   Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application

 

 

 

____    2.         Which of the following is an example of a cluster of related cues?

1)

Complains of nausea and stomach pain after eating

2)

Has a productive cough and states stools are loose

3)

Has a daily bowel movement and eats a high-fiber diet

4)

Respiratory rate 20 breaths/min, heart rate 85 beats/min, blood pressure 136/84

 

ANS:   1

A cue is an unhealthy response; a cluster of cues consists of cues related to each other. 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.

 

PTS:    1          DIF:    Difficult          REF:    pp. 62

KEY:   Nursing process: Diagnosis  | Client need: PHSI | Cognitive level: Analysis

 

 

 

____    3.         Which of the following explains why it is important to have the correct etiology for a nursing diagnosis? The etiology

1)

Is the cause of the problem

2)

Cannot always be observed

3)

Directs nursing care

4)

Is an inference

 

ANS:   3

The etiology directs nursing interventions. If the incorrect etiology is given, the nursing care would not be appropriate for the client. The other statements are true but not a reason for the importance of the etiology being correct.

 

PTS:    1          DIF:    Difficult          REF:    pp. 63

KEY:   Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis

 

 

 

____    4.         How does a risk nursing diagnosis differ from a possible nursing diagnosis?

1)

A risk diagnosis is based on data about the patient.

2)

A possible diagnosis is based on partial (or incomplete) data.

3)

Nurses collect the data to support risk diagnoses.

4)

A possible diagnosis becomes an actual diagnosis when symptoms develop.

 

ANS:   2

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.

 

PTS:    1          DIF:    Moderate         REF:    p. 60

KEY:   Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis

 

 

 

____    5.         Which of the following describes the difference between a collaborative problem and a medical diagnosis?

1)

A collaborative problem is treated by the nurse; a physician is responsible for the treatment of a medical problem.

2)

A collaborative problem is a nursing diagnosis that requires specific orders from a physician; a medical diagnosis directs all nursing care.

3)

A collaborative problem has the potential to become an actual nursing diagnosis; a medical diagnosis rarely changes.

4)

A collaborative problem requires intervention by the nurse and physician or other professional; a medical diagnosis requires intervention by a physician.

 

ANS:   4

Collaborative problems are physiological complications a client may be at risk for due to 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.

 

PTS:    1          DIF:    Moderate         REF:    pp. 58–59

KEY:   Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis