Chapter 12 My Nursing Test Banks

Kozier & Erbs Fundamentals of Nursing, 10/E
Chapter 12

Question 1

Type: MCSA

After an assessment, the nurse reviews the list of client problems. For which problems should the nurse create nursing diagnoses?

1. The ones that the nurse is licensed to treat

2. The ones that address other health professionals interventions

3. The ones that focus on the clients primary illness

4. The ones that have standardized care available

Correct Answer: 1

Rationale 1: The domain of nursing diagnoses includes only those health states that nurses are educated on and licensed to treat. A nursing diagnosis is a judgment made only after data collection. Nursing diagnoses describe a continuum of health states: deviations from health, presence of risk factors, and areas of enhanced personal growth.

Rationale 2: A nursing diagnosis, although familiar to other health care professionals, is nursing focused.

Rationale 3: The nursing diagnosis statement is specific to nursing and nurses and does not include the medical diagnosis.

Rationale 4: The nursing diagnosis, like the plan of care, is specific to each individual client and the clients situation.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: II.B. 4. Function competently within own scope of practice as a member of the health care team

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3. Compare nursing diagnoses, medical diagnoses, and collaborative problems.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 177

Question 2

Type: MCSA

A client comes to the clinic seeking information and education regarding healthy lifestyles and eating habits. Which type of diagnosis should the nurse select for this client?

1. Risk nursing diagnosis

2. Syndrome diagnosis

3. Wellness diagnosis

4. Actual diagnosis

Correct Answer: 3

Rationale 1: A risk diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervenethat is not what is described in this scenario.

Rationale 2: A syndrome diagnosis is associated with a cluster of other diagnosesthat is not what is described in this scenario.

Rationale 3: A wellness diagnosis describes the human response to levels of wellness in an individual. This client is seeking information about behavior changes and improvement to assist him in making choices and changes to enhance his life.

Rationale 4: An actual diagnosis is a client problem that is present at the time of the nursing assessment.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: II.B. 4. Function competently within own scope of practice as a member of the health care team

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 1. Differentiate nursing diagnoses according to status.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 183

Question 3

Type: MCSA

A client who has been in a wheelchair for several years is currently experiencing problems with skin breakdown and urinary retention in addition to depression. Which diagnosis should the nurse select for this client?

1. Syndrome diagnosis

2. Risk nursing diagnosis

3. Actual diagnosis

4. Wellness diagnosis

Correct Answer: 1

Rationale 1: A syndrome diagnosis is a diagnosis that is associated with a cluster of other diagnoses (in this situation, Urinary elimination alteration, Impaired skin integrity, and Powerlessness).

Rationale 2: A risk nursing diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless the nurse intervenes.

Rationale 3: An actual diagnosis is a client problem that is present at the time of the nursing assessment.

Rationale 4: A wellness diagnosis describes human responses to levels of wellness in an individual, family, or community that has a readiness for enhancement.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: II.B. 4. Function competently within own scope of practice as a member of the health care team

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 1. Differentiate nursing diagnoses according to status.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 176

Question 4

Type: MCSA

The nurse is preparing to write nursing diagnoses for a client. What should the nurse recall about the NANDA label?

1. Must contain three components

2. Describes the health problem for which nursing therapy is given

3. Helps define medical diagnoses for nursing

4. Promotes a taxonomy of nursing

Correct Answer: 4

Rationale 1: The diagnosis contains three components: the problem and its definition, the etiology, and the defining characteristics.

Rationale 2: The problem statement, or diagnostic label, describes the clients health problem or response for which nursing therapy is given.

Rationale 3: The nursing diagnosis is not equated with or defined by medical diagnoses.

Rationale 4: The purpose of the NANDA label is to define, refine, and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses. This label describes the health problem or response by the client for which nursing therapy is given.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: II.B. 4. Function competently within own scope of practice as a member of the health care team

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in

planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 2. Identify the components of a nursing diagnosis.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 176

Question 5

Type: MCSA

An experienced nurse has just walked into the room of a newly assigned client. Which observation should the nurse use to include a new nursing diagnosis in this clients plan of care?

1. The clients eyes are closed.

2. The clients skin is pale and mottled.

3. The clients spouse is asleep in the chair next to the bed.

4. The television is on and the volume is turned up.

Correct Answer: 2

Rationale 1: Nurses draw on knowledge and experience to compare client data to standards and norms and to identify significant and relevant observations. A sleeping client would not necessarily be recognized as a significant or relevant observation.

Rationale 2: Nurses draw on knowledge and experience to compare client data to standards and norms and to identify significant and relevant observations. An observation is considered significant if it points to changes in the clients health status or pattern, varies from norms of the client population, or indicates a developmental delay. Pale, mottled skin could indicate coldness, a problem with circulation, or even death.

Rationale 3: Nurses draw on knowledge and experience to compare client data to standards and norms and to identify significant and relevant cues. A clients spouse asleep in a chair would not necessarily be recognized as a significant or relevant observation.

Rationale 4: Nurses draw on knowledge and experience to compare client data to standards and norms and to identify significant and relevant cues. A television playing loudly would not necessarily be recognized as a significant or relevant observation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: II.B. 4. Function competently within own scope of practice as a member of the health care team

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 1. Differentiate nursing diagnoses according to status.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 178

Question 6

Type: MCSA

The nurse selects the nursing diagnosis of Enhanced readiness for spiritual well-being for a family. Which data cluster did the nurse use to support this diagnosis?

1. The family visits different congregations, the parents have been reflecting on their own spiritual upbringings, and the children are questioning rituals of their friends and friends families.

2. The children attend Sunday school classes, one parent always attends services with the children, and the parents attempt interaction with congregational activities.

3. The grandparents go to weekly services and have formal interaction with clergy.

4. The children have attended private, religious schools, and the parents are involved in the schools activities.

Correct Answer: 1

Rationale 1: A wellness diagnosis describes human responses to levels of wellness in an individual family or community that has a readiness for enhancement or improvement. The data cluster that describes the questioning, searching, and reflecting would support an attitude of readiness.

Rationale 2: A wellness diagnosis describes human responses to levels of wellness in an individual family or community that has a readiness for enhancement or improvement. This option merely shows activities but no real interest in improvement.

Rationale 3: A wellness diagnosis describes human responses to levels of wellness in an individual family or community that has a

readiness for enhancement or improvement. This option merely shows activities but no real interest in improvement on the part of only specific family members.

Rationale 4: A wellness diagnosis describes human responses to levels of wellness in an individual family or community that has a readiness for enhancement or improvement. This option merely shows activities but no real interest in improvement.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 1. Differentiate nursing diagnoses according to status.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 176

Question 7

Type: MCSA

The graduate nurse is struggling with identifying cues from clustered data. What should the nurse use to recognize data patterns and cues?

1. Depend on knowledge gained from peers experiences.

2. Work with seasoned and experienced nurses and learn from them.

3. Take assessment notes and utilize information from textbooks for comparison.

4. Know that this will take time, and experience is the best teacher.

Correct Answer: 3

Rationale 1: Learning from peers is helpful, but does not take the place of didactic information.

Rationale 2: Learning from seasoned nurses is helpful, but does not take the place of didactic information.

Rationale 3: The novice nurse must take careful assessment notes, search data for abnormal cues, and use textbook resources for comparing the clients cues with the defining characteristics and etiologic factors of the accepted nursing diagnoses.

Rationale 4: Experience teaches much information, but it never takes the place of concrete, scientific theory.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Identify the basic steps in the diagnostic process.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 179

Question 8

Type: MCSA

The nurse has formulated a diagnosis of Activity intolerance related to decreased airway capacity for a client with chronic asthma. In looking at the clients coping skills, the nurse realizes that the client has a vast knowledge about the disease and what exacerbates symptoms in particular situations. Why should the nurse utilize this information?

1. Strengths can be an aid to mobilizing health and the healing process.

2. The client will be more active in the plan.

3. It will be easier for the nurse to educate the client about other interventions.

4. The nurse wont have to spend time going over the pathology of the clients disease.

Correct Answer: 1

Rationale 1: Establishing strengths, resources, and ability to cope will help the client develop a more well-rounded self-concept and self-image. Strengths can be an aid to mobilizing health and regenerative processes.

Rationale 2: The client may be more active in the plan; however, this does not explain why the client will be more active.

Rationale 3: Looking at what will be easier for the nurse is not the reason strengths are included in the clients plan.

Rationale 4: Looking at what will be time effective for only the nurse is not the reason strengths are included in the clients plan.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Identify the basic steps in the diagnostic process.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 181

Question 9

Type: MCSA

A client has been having pain without any clear pathology for cause. Which nursing diagnosis should the nurse identify as being the most appropriate for this client?

1. Pain due to unknown factors

2. Pain related to unknown etiology

3. Pain caused by psychosomatic condition

4. Pain manifested by clients report

Correct Answer: 2

Rationale 1: The second part of the nursing diagnosis statement is the etiology (E)the factors contributing to or probable causesand should be joined to the first part, the problem (P), by the words related to rather than due to.

Rationale 2: The second part of the nursing diagnosis statement is the etiology (E)the factors contributing to or probable causesand should be joined to the first part, the problem (P), by the words related to rather than due to. The phrase related to implies a relationship between the problem and the cause. In this situation, the cause is unknown, but the problem is evident.

Rationale 3: Making an assumption that the cause is psychosomatic is not within the nurses scope of practice.

Rationale 4: The third part of the nursing diagnosis statement is manifested by the (S) portion, which includes the signs and symptoms, not a generalized statement.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 1. Differentiate nursing diagnoses according to status.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 182

Question 10

Type: MCSA

A client is diagnosed with pneumonia and has been hospitalized for several days. Which nursing diagnosis should the nurse identify as a priority for this client?

1. Altered oral mucous membranes, related to dry mouth

2. Activity intolerance, related to oxygen supply imbalance

3. Knowledge deficit, related to medication regimen

4. Ineffective airway clearance, related to increased secretions

Correct Answer: 4

Rationale 1: Prioritizing care must begin with the basic needs. This option is appropriate but does not match the primary need.

Rationale 2: Prioritizing care must begin with the basic needs. This option is appropriate but does not match the primary need.

Rationale 3: Prioritizing care must begin with the basic needs. This option is appropriate but does not match the primary need.

Rationale 4: Prioritizing care must begin with the basic needs, in this case, the airway.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 1. Differentiate nursing diagnoses according to status.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 185


Question 11

Type: MCSA

The nurse is caring for a client recovering from a long and difficult childbirth experience. Which nursing diagnosis did the nurse write appropriately for this client?

1. Constipation, due to tissue trauma, manifested by no bowel movement for 2 days

2. Risk for infection, because of new incision, related to episiotomy

3. Ineffective breast-feeding, related to lack of motivation, secondary to exhaustion

4. Altered urinary elimination, secondary to childbirth

Correct Answer: 3

Rationale 1: Manifested is not appropriate wording of the NANDA statement.

Rationale 2: Because of is not appropriate wording of the NANDA statement.

Rationale 3: The problem statement is listed first (NANDA label), followed by the etiologyfactors that contribute to or are the cause of the clients response. The two parts are joined by the words related to, implying a relationship between the two. Adding a second part to the etiology statement makes it more descriptive and useful.

Rationale 4: The problem statement is listed first (NANDA label), followed by the etiologyfactors that contribute to or are the cause of the clients responsewhich is lacking in this option.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 6. List guidelines for writing a nursing diagnosis statement.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 182

Question 12

Type: MCSA

The nurse is formulating a nursing diagnosis for a client with a long, extensive history of psychiatric problems, beginning in childhood, who is being placed in a long-term, structured institutional environment. Which diagnosis indicates the clients problem is adequately described?

1. Chronic low self-esteem, related to factors too numerous to mention

2. Risk for self-harm, related to many psychiatric problems

3. Impaired social interaction, due to long history of institutionalization

4. Alteration in thought processes, related to complex factors

Correct Answer: 4

Rationale 1: This option poorly describes the causing factors.

Rationale 2: This option poorly describes the causing factors.

Rationale 3: This option limits the description of causing factors.

Rationale 4: The phrase complex factors may be used when there are too many etiologic factors or when they are too complex to state in a brief phrase. The actual cause of this clients altered thought process may be due to psychiatric diagnoses, medication tolerances and noncompliance, history of institutionalization, and life history of mental disease. This is a variation of the basic two-part statement, but is acceptable to use.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 6. List guidelines for writing a nursing diagnosis statement.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 182

Question 13

Type: MCSA

After communicating with the client and family, the nurse compares a clients problem list with identified nursing diagnoses. What action is the nurse performing to minimize diagnostic errors?

1. Understanding what is normal vs. what is not normal

2. Verifying

3. Consulting resources

4. Basing diagnoses on patterns

Correct Answer: 2

Rationale 1: Nurses must apply knowledge from various areas to recognize cues and patterns to understand what is normal and not normal. This comes from principles of chemistry, anatomy, and pharmacologynot the client or the family.

Rationale 2: The nurse, while taking the information and collecting data, begins to hypothesize possible explanations of the data and then realizes all diagnoses are only tentative until they are verified. The client and family should be included in the beginning and also at the end of the diagnostic process to verify the nurses diagnoses.

Rationale 3: Both novices and experienced nurses should consult appropriate resources whenever in doubt about a diagnosis; that is not what is described in the scenario.

Rationale 4: Diagnoses should be based on patterns and behavior over time, not an isolated incident.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. List guidelines for writing a nursing diagnosis statement.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 184

Question 14

Type: MCSA

After formulating several diagnoses, the nurse does not understand the reason for some of the discrepancies in the clients lab values and diagnostic tests, when comparing to norms and standards. Which action should the nurse take?

1. Verify the information with the client.

2. Compare all findings to the national norms and standards.

3. Consult other professionals and colleagues.

4. Improve critical thinking skills so answers come more easily.

Correct Answer: 3

Rationale 1: Verifying the information with the client would be inappropriate because the information does not come from subjective data, but rather from testing and lab values.

Rationale 2: The nurse already has compared the findings to the norms and standards.

Rationale 3: Both novices and experienced nurses should consult appropriate resources whenever in doubt about a diagnosis. Professional literature, nursing colleagues, and other professionals are all appropriate resources.

Rationale 4: Critical-thinking skills help the nurse be aware of and avoid errors. This comes with experience and is a learned and practiced process.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Identify the basic steps in the diagnostic process.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 184

Question 15

Type: MCSA

The nurse has completed the initial assessment of a client and has analyzed and clustered the data. What should the nurse complete next in the diagnostic process?

1. Formulate a diagnosis.

2. Verify the data.

3. Research collaborative and nursing-related interventions.

4. Identify the clients problem, health risks, and strengths.

Correct Answer: 4

Rationale 1: There are steps in the process that precede the formulation of diagnostic statements.

Rationale 2: Verifying the data should be done at the end of the assessment/interview phase.

Rationale 3: Researching collaborative and nursing-related interventions comes after setting goals or outcomes and is not part of the diagnostic process, but rather part of the implementation phase.

Rationale 4: The step that follows data analysis is identification of the clients health problems, health risks, and strengths.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 4. Identify the basic steps in the diagnostic process.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 179

Question 16

Type: MCSA

The nurse has formulated the following diagnosis: Activity intolerance, related to weakness and debilitation, manifested by reports of fatigue after any physical activity. What is the defining characteristic of this label?

1. Activity intolerance

2. Weakness and debilitation

3. Reports of fatigue

4. Physical activity

Correct Answer: 3

Rationale 1: Activity intolerance is the NANDA label and identifies the problem, but reports of fatigue is the defining characteristic.

Rationale 2: Weakness and debilitation are the etiology (underlying cause), but reports of fatigue is the defining characteristic.

Rationale 3: The defining characteristics are those reports given by the client, or the signs and symptoms.

Rationale 4: Physical activity is what brings on the reports of the defining characteristic, but reports of fatigue is the defining characteristic.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 2. Identify the components of a nursing diagnosis.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 182

Question 17

Type: MCSA

A client who has just been diagnosed with pancreatic cancer is quite upset and verbal. The nurse has formulated the following diagnosis: Anxiety, related to unfamiliarity of disease process, manifested by restlessness and tachycardia. What is the etiology of this diagnosis?

1. Unfamiliarity of disease process

2. Anxiety

3. Restlessness

4. Tachycardia

Correct Answer: 1

Rationale 1: The etiology is the underlying cause and a contributing factor of the clients response. In this case, the uncertainty of the diagnosis, fear of the unknown, and response to the diagnosis cause the client to become anxious and upset.

Rationale 2: Anxiety is the NANDA labelthe problem identified.

Rationale 3: Restlessness is a defining characteristic that the client exhibits.

Rationale 4: Tachycardia is a defining characteristic that the client exhibits.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 2. Identify the components of a nursing diagnosis.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 182

Question 18

Type: MCSA

The nurse formulates the nursing diagnosis: Acute pain, related to tissue damage, secondary to infarction, manifested by pallor, client report, and shallow, rapid breathing for a client experiencing an acute myocardial infarction. Which collaborative action would be appropriate for this client?

1. Provide a calm, quiet atmosphere in the clients room.

2. Administer pain medication.

3. Educate the client and family regarding treatment and therapies.

4. Monitor for changes in the clients condition.

Correct Answer: 2

Rationale 1: This option is not collaborative but rather nurse mediated, which the nurse can implement independently.

Rationale 2: Collaboration occurs between the nurse, physician, and other health care professionals to treat the clients problem. In this case, the physician prescribes medications, and the nurse administers thema primarily dependent action that requires physician orders.

Rationale 3: This option is not collaborative but rather nurse mediated, which the nurse can implement independently.

Rationale 4: This option is not collaborative but rather nurse mediated, which the nurse can implement independently.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Differentiate nursing diagnoses according to status.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 183

Question 19

Type: MCMA

The nurse has formulated a nursing diagnosis of Impaired skin integrity related to poor hygienic practice, secondary to current living conditions for a client. Which data did the nurse use to support this diagnosis?

Standard Text: Select all that apply.

1. The client has dry, cracked skin.

2. The client has one large and several smaller open, ulcerated areas on his right leg.

3. The client does not drive.

4. The client states that he does not use alcohol or drugs.

5. The clients clothes are soiled.

6. The client has obvious body odor.

Correct Answer: 1, 2, 5, 6

Rationale 1: Data that support this problem are clustered around the condition of the clients skin.

Rationale 2: Data that support this problem are clustered around the condition of the clients skin.

Rationale 3: The fact that the client does not drive does not play a part in this clients skin condition.

Rationale 4: The fact that the client does not use alcohol or drugs does not play a part in this clients skin condition.

Rationale 5: Data that support this problem are clustered around the condition of the clients clothes.

Rationale 6: Data that support this problem are clustered around the condition of the clients general appearance.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 4. Identify the basic steps in the diagnostic process.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 179

Question 20

Type: MCSA

The nurse is reviewing information about the formulation of nursing diagnoses. What should the nurse identify as the area in which nursing diagnoses differ from medical diagnoses and collaborative problems?

1. Mental status of the client

2. Chronic nature of the illness

3. Nursing care focus

4. Prognosis

Correct Answer: 3

Rationale 1: This is not considered and so is not an area of difference.

Rationale 2: This is not considered and so is not an area of difference.

Rationale 3: Nursing focus is an area that differs.

Rationale 4: This is not considered and so is not an area of difference.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 3. Compare nursing diagnoses, medical diagnoses, and collaborative problems.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 176

Question 21

Type: MCMA

The nurse is using the Taxonomy II nursing diagnoses system. What axes should the nurse realize are coded within this system?

Standard Text: Select all that apply.

1. Gordons health pattern groupings

2. Age

3. Time

4. Health status

5. Gender

6. Location

Correct Answer: 2, 3, 4, 6

Rationale 1: The diagnoses are no longer grouped by Gordons patterns.

Rationale 2: The Taxonomy II system codes diagnoses according to seven axes that include age.

Rationale 3: The Taxonomy II system codes diagnoses according to seven axes that include time.

Rationale 4: The Taxonomy II system codes diagnoses according to seven axes that include health status.

Rationale 5: Gender is not an axis upon which diagnoses are coded.

Rationale 6: The Taxonomy II system codes diagnoses according to seven axes that includes location.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 5. Describe various formats for writing nursing diagnoses.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 185

Question 22

Type: MCMA

The nurse is reviewing assessment data collected for a clients care plan. What criteria should the nurse use when formulating this clients nursing diagnoses?

Standard Text: Select all that apply.

1. Nonjudgmental statements

2. Stated in terms of a need

3. Must be legally advisable

4. Cause/effect correctly stated

5. Medical terminology used to describe the cause

6. Diagnosis worded specifically and precisely

Correct Answer: 1,3,4,6

Rationale 1: This option reflects an accepted guideline for formulating nursing diagnoses.

Rationale 2: A nursing diagnosis statement must be stated in terms of a problem, not a need.

Rationale 3: This option reflects an accepted guideline for formulating nursing diagnoses.

Rationale 4: This option reflects an accepted guideline for formulating nursing diagnoses.

Rationale 5: Nursing terminology rather than medical terminology is used to describe the clients response and the probable cause of the clients response.

Rationale 6: This option reflects an accepted guideline for formulating nursing diagnoses.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 6. List guidelines for writing a nursing diagnosis statement.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 184

Question 23

Type: MCSA

The nurse wants to propose a new nursing diagnosis. What action should the nurse take first?

1. Using the proposed nursing diagnosis when constructing client care plans

2. Getting permission for the proposed nursing diagnosis to be implemented by a nursing facility

3. Submitting the diagnosis to NANDAs Diagnostic Review Committee

4. Presenting the proposed nursing diagnosis at the local AMA (American Medical Association) meeting.

Correct Answer: 3

Rationale 1: This option is inappropriate because only approved nursing diagnoses should be used to direct nursing care.

Rationale 2: This is not the appropriate method for having a new nursing diagnosis included for use.

Rationale 3: This is the recognized procedure for initiating the approval of a new nursing diagnosis.

Rationale 4: This option is inappropriate because nursing diagnoses are not a part of medical care.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 7. Describe the evolution of the nursing diagnosis movement, including work currently in progress.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 185

Question 24

Type: MCMA

The nurse is providing care to a client. Which nursing diagnoses can the nurse apply when providing client care?

Standard Text: Select all that apply.

1. Ineffective Breathing Pattern

2. Risk of Infection

3. Readiness for Enhanced Nutrition

4. Readiness for Enhanced Family Coping

5. Anxiety

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