Chapter 12 My Nursing Test Banks

 

Kozier & Erbs Fundamentals of Nursing, 9/E
Chapter 12

Question 1

Type: MCSA

A nursing student is learning the application of the nursing process to client care. When questioned by the student about the reason for implementing a nursing diagnosis, the nursing professor responds: The nursing diagnosis statement:

1. Describes client problems that nurses are licensed to treat.

2. Helps other health care professionals understand the plan of care.

3. Includes the disease the client has during the treatment of care.

4. Helps standardize care for all clients.

Correct Answer: 1

Rationale 1: The domain of nursing diagnoses includes only those health states that nurses are educated 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 while familial to other healthcare 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: Page Reference: 200

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 03 Compare nursing diagnoses, medical diagnoses, and collaborative problems.

Question 2

Type: MCSA

A client comes to the clinic seeking information and education regarding healthy lifestyles and eating habits. The most appropriate diagnosis for this client is which of the following?

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 intervene-that is not what is described in this items.

Rationale 2: A syndrome diagnosis is associated with a cluster of other diagnoses that is not what is described in this stem.

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: Page Reference: 201

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 01 Differentiate nursing diagnoses according to status.

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. When formulating a nursing diagnosis, an appropriate selection would be which of the following?

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). Currently, there are six syndrome diagnoses on the NANDA International list.

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: Page Reference: 208

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 02 Identify the components of a nursing diagnosis

Question 4

Type: MCSA

Which of the following is true of 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 purpose of NANDA 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. It contains three components: the problem and its definition, the etiology, and the defining characteristics. The nursing diagnosis is not equated nor defined by medical diagnoses.

Rationale 2: The purpose of NANDA 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. It contains three components: the problem and its definition, the etiology, and the defining characteristics. The nursing diagnosis is not equated nor defined by medical diagnoses.

Rationale 3: The purpose of NANDA 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. It contains three components: the problem and its definition, the etiology, and the defining characteristics. The nursing diagnosis is not equated nor defined by medical diagnoses.

Rationale 4: The purpose of NANDA 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. It contains three components: the problem and its definition, the etiology, and the defining characteristics. The nursing diagnosis is not equated nor defined by medical diagnoses.

Global Rationale: Page Reference: 201

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 03 Describe various formats for writing nursing diagnoses.

Question 5

Type: MCSA

An experienced nurse has just walked into the room of a client to whom the nurse has been assigned for the shift. Which of the following might be a significant observation that could influence the inclusion of a new nursing diagnosis?

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 observation. A 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: Page Reference: 204-206

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 01 Differentiate nursing diagnoses according to status.

Question 6

Type: MCSA

A nursing diagnosis of Enhanced readiness for spiritual well-being has been formulated for a particular family. Which of the following data clusters would 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 school, 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 show 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 show 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 show activities but no real interest in improvement.

Global Rationale: Page Reference: 204

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 02 Identify the components of a nursing diagnosis.

Question 7

Type: MCSA

The student nurse understands that clustering data comes with experience and recognizing cues. The best way for this student to recognize patterns or cues in the data is to:

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: Page Reference: 204

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Identify the basic steps in the diagnostic process

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. The nurse will utilize this information because:

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 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: Yes, the client may be more active in the plan, but theris an option is more inclusive and gives the reason 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: Page Reference: 204

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Identify the basic steps in the diagnostic process.

Question 9

Type: MCSA

A client has been having pain without any clear pathology for cause. The most appropriately written nursing diagnosis for this client would be which of the following?

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 causes and 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 causes and 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 the manifested by (S) portion, which includes the signs and symptoms not a generalized statement.

Global Rationale: Page Reference: 207

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 01 Differentiate nursing diagnoses according to status.

Question 10

Type: MCSA

A client is diagnosed with pneumonia and has been hospitalized for several days. A priority nursing diagnosis for this client is which of the following?

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: Page Reference: 210

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 01 Differentiate nursing diagnoses according to status.

Question 11

Type: MCSA

A client just had a baby following a long labor and difficult delivery. Which of the following nursing diagnoses is formulated correctly?

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 response lacking in this option.

Global Rationale: Page Reference: 207-209

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 06 List guidelines for writing a nursing diagnosis statement.

Question 12

Type: MCSA

Which of the following would be a correctly formulated diagnosis for a client with a long, extensive history of psychiatric problems, beginning in childhood. that is being placed in a long-term, structured institutional environment?

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 acceptable to use.

Global Rationale: Page Reference: 207-208

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 06 List guidelines for writing a nursing diagnosis statement.

Question 13

Type: MCSA

When reviewing both the clients problem list against the various identified nursing diagnoses, both of which included client and family input, the nurse is utilizing of the following processes to minimize diagnostic error?

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 stem.

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

Global Rationale: Page Reference: 209

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 06 List guidelines for writing a nursing diagnosis statement.

Question 14

Type: MCSA

The nurse, after formulating several diagnoses for a client, 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 of the following is the best action of the nurse?

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 since the information does not come from subjective data, 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: Page Reference: 209

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 04 Identify the basic steps in the diagnostic process.

Question 15

Type: MCSA

The nurse has completed the initial assessment of a client and has analyzed and clustered the data. The nurses next step in the diagnostic process is to:

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 precedes 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, 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: Page Reference: 207

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 04 Identify the basic steps in the diagnostic process.

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 is the defining characteristic.

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

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

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

Global Rationale: Page Reference: 204

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 02 Identify the components of a nursing diagnosis.

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. The etiology of this diagnosis is which of the following?

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. Anxiety is the NANDA labelthe problem identified. Restlessness and tachycardia are the defining characteristics which the client exhibits.

Rationale 2: 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. Anxiety is the NANDA labelthe problem identified. Restlessness and tachycardia are the defining characteristics which the client exhibits.

Rationale 3: 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. Anxiety is the NANDA labelthe problem identified. Restlessness and tachycardia are the defining characteristics which the client exhibits.

Rationale 4: 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. Anxiety is the NANDA labelthe problem identified. Restlessness and tachycardia are the defining characteristics which the client exhibits.

Global Rationale: Page Reference: 207

Cognitive Level: Understanding

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 02 Identify the components of a nursing diagnosis.

Question 18

Type: MCSA

A client has been admitted to the cardiac intensive care unit following an acute myocardial infarction. The nurse formulates the following nursing diagnosis: Acute pain, related to tissue damage, secondary to infarction, manifested by pallor, client report, and shallow, rapid breathing. Which of the following would be an example of a collaborative intervention?

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: Page Reference: 207

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 Differentiate nursing diagnoses according to status.

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. Which of the following data would support this diagnosis?

Standard Text: Select all that apply.

1. Skin is dry, cracked

2. One large with several smaller open, ulcerated areas on right leg

3. Client does not drive

4. Client states that does not use alcohol or drugs

5. Clothes are soiled

6. 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: Page Reference: 204-205

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 04 Identify the basic steps in the diagnostic process.

Question 20

Type: MCSA

Nursing diagnoses are different from medical diagnoses and collaborative problems in areas that include:

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 so is not an area of difference.

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

Rationale 3: Nursing focus is an area that differs.

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

Global Rationale: Page Reference: 202

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 03 Compare nursing diagnoses, medical diagnoses, and collaborative problems.

Question 21

Type: MCMA

The student nurse is learning the Taxonomy II nursing diagnoses system. This system is coded according to which of the following axes?

Standard Text: Select all that apply.

1. Gordons health pattern groupings

2. Age

3. Time

4. Health status

5. Gender

6. Unit of care

Correct Answer: 2,3,4,6

Rationale 1: Health patterns is not a axes upon which diagnoses are coded.

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

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

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

Rationale 5: Gender is not a axes upon which diagnoses are coded.

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

Global Rationale: Page Reference: 200, 210

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 05 Describe various formats for writing nursing diagnoses.

Question 22

Type: MCMA

The nurse is reviewing the clients care plan and checking the quality of the nursing diagnosis statements. Criteria to use for guidelines in formulating nursing diagnoses include which of the following?

Standard Text: Select all that apply.

1. Nonjudgmental statements

2. Stated in terms of a need

3. Must be legally advisable

4. Cause/effect are correctly stated

5. Use medical terminology to describe the cause

6. Word the diagnosis specifically and precisely

Correct Answer: 1,3,4,6

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

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

Global Rationale: Page Reference: 209-210

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 06 List guidelines for writing a nursing diagnosis statement.

Question 23

Type: MCSA

The nurse wishing to propose a new nursing diagnosis would initiate the process by:

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 diagnoses 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 since 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 since nursing diagnoses are not a part of medical care.

Global Rationale: Page Reference: 210

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 07 Describe the evolution of the nursing diagnosis movement, including work currently in progress.

Question 24

Type: MCMA

The nurse applies an actual nursing diagnoses when selecting:

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

Correct Answer: 1,5

Rationale 1: An actual diagnosis is a client problem that is present at the time of the nursing assessment. An actual nursing diagnosis is based on the presence of associated signs and symptoms.

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 nurses intervene.

Rationale 3: A health promotion diagnosis relates to the clients preparedness for implementing behaviors to improve their health condition. These diagnosis labels begin with the phrase readiness for enhanced.

Rationale 4: A wellness diagnosis describes human responses to levels of wellness in an individual, family or community. These diagnosis labels begin with the phrase readiness for enhanced.

Rationale 5: An actual diagnosis is a client problem that is present at the time of the nursing assessment. An actual nursing diagnosis is based on the presence of associated signs and symptoms.

Global Rationale: Page Reference: 200

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 Differentiate nursing diagnoses according to status.

Question 25

Type: MCMA

A nursing diagnosis that was written according to the PES format model would include:

Standard Text: Select all that apply.

1. Ineffective coping related to depression as evidenced by suicide attempt

2. Noncompliance (DASH diet) related to denial of having disease

3. Risk for infection related to recent surgery

4. Nutrition less than adequate related to anxiety as evidenced by weight loss of ten pounds

5. Ineffective Breathing Pattern as evidenced by cyanotic lips

Correct Answer: 1,4

Rationale 1: The basic three-part nursing diagnosis statement is called the PES format and includes the problem, etiology, and signs and symptoms.

Rationale 2: The basic three-part nursing diagnosis statement is called the PES format and includes the problem, etiology, and signs and symptoms; this diagnosis is lacking the signs and symptoms.

Rationale 3: The basic three-part nursing diagnosis statement is called the PES format and does not support the use of risk for diagnosis because the client does not have signs and symptoms of the diagnosis.

Rationale 4: The basic three-part nursing diagnosis statement is called the PES format and includes the problem, etiology, and signs and symptoms.

Rationale 5: The basic three-part nursing diagnosis statement is called the PES format and includes the problem, etiology, and signs and symptoms; this diagnosis is lacking the etiology.

Global Rationale: Page Reference: 207

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 05 Describe various formats for writing nursing diagnoses.

Kozier & Erbs Fundamentals of Nursing, 9/E Test Bank

Copyright 2012 by Pearson Education, Inc.

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