Nursing Competencies: Exam 2 Test
Questions And Answers 100% Pass.
Of the following problem-focused nursing diagnoses which are stated correctly:
- Impaired Skin Integrity r/t physical immobility
- Fatigue r/t heart disease
- Nausea r/t gastric distention
- Need fro improved Oral Mucosa Integrity r/t inflamed mucosa
- Risk for infection r/t surgery - answer✔Correct:
- Impaired Skin Integrity r/t physical immobility
- Nausea r/t gastric distention
Explanation: The related factors in diagnoses "Fatigue related to heart disease" and "Need for
improved oral mucosa integrity related to inflamed mucosa" are incorrect. The related factor of a
medical diagnosis (in Fatigue related to heart disease) cannot be corrected through nursing
intervention. In "Need for improved oral mucosa integrity related to inflamed mucosa" there is
no diagnosis, but instead a goal of care. "Risk for infection related to surgery" is incorrect; risk
nursing diagnoses do not have defining characteristics or related factors because they have not
occurred yet.
A nurse reviews data gathered regarding a patient's ability to cope with loss. The nurse compares
the defining characteristics for Ineffective Coping with those for Readiness for Enhanced Coping
and selects Ineffective Coping as the correct diagnosis. This is an example of the nurse avoiding
an error in: (Select all that apply.)
Data collection
Data clustering
Data interpretation
Making a diagnostic statement
Goal setting - answer✔Data collection
Data interpretation
Explanation: This is an example of an error in interpretation and data collection. When making a
diagnosis, the nurse must interpret data that he or she has collected by identifying and organizing
relevant assessment patterns to support the presence of patient problems. In the case of the two
diagnoses in this question, there can be conflicting cues. The nurse must obtain more information
and recognize the cues that point to the correct diagnosis.
The use of standard formal nursing diagnostic statements serves several purposes in nursing
practice, including which of the following? (Select all that apply.)
-Defines a patient's problem, giving members of the health care team a common language for
understanding the patient's needs
- Allows physicians and allied health staff to communicate with nurses how they provide care
among themselves
-Helps nurses focus on the scope of nursing practice
-Creates practice guidelines for collaborative health care activities
-Builds and expands nursing knowledge - answer✔Correct:
Defines a patient's problem, giving members of the health care team a common language for
understanding the patient's needs
Helps nurses focus on the scope of nursing practice
Builds and expands nursing knowledge
knowledge base - answer✔NOT experience or policy and procedure manuals
IS reading current evidence from literature
holistic vie of patient needs
application of nursing theory
making decisions about a group of patients: - answer✔combine activities to resolve more than
one patient problem
consider use of assistive personnel
analyze diagnoses/problems and decide which are most urgent based on patient needs
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