After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse's actions?
A) To form a language that can be encoded only by nurses
B) To distinguish the nurse's role from the physician's role
C) To develop clinical judgment based on other's i...
After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the
rationale for the nurse's actions?
A) To form a language that can be encoded only by nurses
B) To distinguish the nurse's role from the physician's role
C) To develop clinical judgment based on other's intuition
D) To help nurses focus on the scope of medical practice - ANS B
Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved?
A) Sore throat
B) Acute pain
C) Sleep apnea
D) Heart failure - ANS B
A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of
pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the
nurse write?
A) Ineffective breathing pattern related to pneumonia
B) Risk for infection related to chest x-ray procedure
C) Risk for deficient fluid volume related to dehydration
D) Impaired gas exchange related to alveolar-capillary membrane changes - ANS D
The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement,
Impaired physical mobility related to tibial fracture as evidenced by patient's inability to
ambulate. Which part of the diagnostic statement does the nurse need to revise?
A) Etiology
B) Nursing diagnosis
C) Collaborative problem
D) Defining characteristic - ANS A
A nurse is using assessment data gathered about a patient and combining critical thinking to
develop a nursing diagnosis. What is the nurse doing?
A) Assigning clinical cues
B) Defining characteristics
C) Diagnostic reasoning
D) Diagnostic labeling - ANS C
,A patient presents to the emergency department following a motor vehicle crash and suffers a
right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other
major injuries, is in good health, and reports only moderate discomfort. Which is the most
pertinent nursing diagnosis the nurse will include in the plan of care?
A) Posttrauma syndrome
B) Constipation
C) Acute pain
D) Anxiety - ANS C
The nurse is reviewing a patient's database for significant changes and discovers that the
patient has not voided in over 8 hours. The patient's kidney function lab results are abnormal,
and the patient's oral intake has significantly decreased since previous shifts. Which step of the
nursing process should the nurse proceed to after this review?
A) Diagnosis
B) Planning
C) Implementation
D) Evaluation - ANS A
A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning
self-catheterization versus assisted catheterization by home health nurses and family members.
The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of
diagnosis did the nurse write?
A) Risk
B) Problem focused
C) Health promotion
D) Collaborative problem - ANS C
A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900.
The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood
pressure was low when it was taken at 0830. The NAP states that was busy and had not had a
chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed.
The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing
process did the nurse first make an error?
A) Assessment
B) Diagnosis
C) Implementation
D) Evaluation - ANS A
A nurse adds the following diagnosis to a patient's care plan: Constipation related to decreased
gastrointestinal motility secondary to pain medication administration as evidenced by the patient
reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which
element did the nurse write as the defining characteristic?
A) Decreased gastrointestinal motility
, B) Pain medication
C) Abdominal distention
D) Constipation - ANS C
The patient database reveals that a patient has decreased oral intake, decreased oxygen
saturation when ambulating, reports of shortness of breath when getting out of bed, and a
productive cough. Which elements will the nurse identify as defining characteristics for the
diagnostic label of Activity intolerance?
A) Decreased oral intake and decreased oxygen saturation when ambulating
B) Decreased oxygen saturation when ambulating and reports of shortness of breath when
getting out of bed
C) Reports of shortness of breath when getting out of bed and a productive cough
D) Productive cough and decreased oral intake - ANS B
A nurse performs an assessment on a patient. Which assessment data will the nurse use as an
etiology for Acute pain?
A) Discomfort while changing position
B) Reports pain as a 7 on a 0 to 10 scale
C) Disruption of tissue integrity
D) Dull headache - ANS C
A new nurse writes the following nursing diagnoses on a patient's care plan. Which nursing
diagnosis will cause the nurse manager to intervene?
A) Wandering
B) Hemorrhage
C) Urinary retention
D) Impaired swallowing - ANS B
A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to
the patient's care plan?
A) Infection
B) Risk for infection
C) Impaired skin integrity
D) Staphylococcal leg infection - ANS C
A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse
document?
A) Decreased cardiac output related to altered myocardial contractility.
B) Patient needs a low-fat diet related to inadequate heart perfusion.
C) Offer a low-fat diet because of heart problems.
D) Acute heart pain related to discomfort. - ANS A
A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge
nurse to follow up?
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