Exam (elaborations)
Chapter 07 Nursing Diagnosis
- Course
- Fundamentals of Nursing
- Institution
- Oxford College Of Emory University
Chapter 07 Nursing Diagnosis
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DAWITChapter 07: Nursing Diagnosis
Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative
Practice, 3RD Edition
MULTIPLE CHOICE
1. The nurse completes a health and physical assessment on a patient admitted with a fractured
pelvis. Which task would 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 OBJ: 7.1 TOP: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Care Coordination
N R I G B.C M
2. A group of patients in a commU
unitS
y ceN
nterTattend O
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 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?
, DAWIT
a. Pericarditis
b. Acute pain
c. Anxiety
d. Activity intolerance
ANS: A
Whereas medical diagnoses identify and label medical (physical and psychological) illnesses,
nursing diagnoses are much broader in and consider a patient‘s response to medical diagnoses
and life situations. The underlying etiology, or cause of a patient‘s concern or situation, rather
than a medical diagnosis, should be used as a related factor when writing an ICNP nursing
diagnosis statement and can be included in the list of supporting data in the EMR. Pericarditis
is a medical diagnosis defined as an inflammation of the pericardium. Pain, anxiety and
intolerance to activity are all possible patient responses to the medical condition of
pericarditis.
DIF: Analyzing OBJ: 7.1 TOP: Evaluation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Care Coordination
4. A patient is receiving an experimental drug for leukemia. The nurse is worried that the drug
may cause a reduction in platelets leading to intestinal tract bleeding. Which type of nursing
diagnosis does the nurse use to address this concern?
a. Risk
b. Actual
c. Health-promotion
d. Medical diagnosis
ANS: A NURSINGTB.COM
The three types of nursing diagnostic statements are actual, risk, and health promotion.
Determining which type is needed for each patient can be challenging. Risk (potential)
Nursing diagnoses apply when there is an increased potential or vulnerability for a patient to
develop a problem or complication. Actual Nursing diagnoses identify existing problems or
concerns of a patient. 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. Medical
diagnoses identify and label medical (physical and psychological) illnesses.
DIF: Remembering OBJ: 7.3 TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Care Coordination
5. The nurse is writing the care plan for a patient admitted to the hospital for complications
associated with muscular dystrophy. Which Nursing diagnoses written on the care plan
indicate a need for further instruction in constructing the diagnostic statement?
a. Constipation related to immobility as manifested patient passing hard, dry stool
with difficulty
b. Activity intolerance related to weakness as evidenced by verbal report of fatigue.
c. Impaired self feeding related to fatigue as manifested by inability to open
containers and bring food to the mouth.
d. Impaired airway clearance related to muscle weakness.
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