Fundamentals of Nursing 4th ed By Delaune – Ladner A+

Description

1. The nurse is working with a client within the assessment phase of the nursing process. Which activity will the nurse NOT do during this phase?

a.	Data collection	c.	Data documentation
b.	Data verification	d.	Data evaluation

ANS: D

The essential elements of the assessment process include data collection, data verification, data organization, data interpretation, and data documentation. Data evaluation is not conducted during this phase of the nursing process.

PTS: 1 DIF: Application REF: Purpose of Assessment

1. The nurse is preparing to conduct a comprehensive assessment with a client. This type of assessment is usually done:

a.	on admission to a health care facility.
b.	on discharge from a health care facility.
c.	to focus in depth on a particular health care problem.
d.	to provide systematic monitoring and observation related to specific problems.

ANS: A

A comprehensive assessment is usually performed upon admission to a health care agency and includes a complete health history to determine current needs of the client. A focused assessment is done to focus in depth on a particular health care problem. An ongoing assessment is an assessment that includes systematic monitoring and observation related to specific problems. An assessment done on discharge from a health care facility is not an identified type of nursing assessment.

PTS: 1 DIF: Application REF: Types of Assessment

1. A client is admitted to the emergency room for treatment of a severe laceration. The type of assessment most likely to be performed by the nurse is a(n):

a.	comprehensive assessment.	c.	ongoing assessment.
b.	focused assessment.	d.	expansive assessment.

ANS: B

A focused assessment is an assessment that is limited in scope in order to focus on a particular need or health care problem or potential health care risk. A comprehensive assessment is usually performed upon admission to a health care agency and includes a complete health history to determine current needs of the client. An ongoing assessment is an assessment that includes systematic monitoring and observation related to specific problems. There is no such category as expansive assessment.

PTS: 1 DIF: Application REF: Types of Assessment

1. The nurse is collecting data from a client. Which of the following would be considered as being subjective data?

a.	The client reports having nausea.
b.	The client’s blood pressure is 120/82.
c.	The client has a reddened area on the buttocks.
d.	The client’s blood sugar is 100 g/dL.

ANS: A

Subjective data are data from the client’s point of view and include feelings, perceptions, and concerns. The data that would be subjective would be “the client reports having nausea.” The other data would be considered as being objective data.

PTS: 1 DIF: Analysis REF: Types of Data

1. The nurse is collecting data from a client. Which of the following would be considered as being objective data?

a.	The client reports having a headache.
b.	The client’s pulse is 88 beats per minute.
c.	The client states that he is frightened.
d.	The client states that he is having pain in his abdomen.

ANS: B

Objective data are measurable data that are obtained through observation, standard assessment techniques performed during the physical examination, and laboratory and diagnostic testing. Of the data provided, the objective data would be “the client’s pulse is 88 beats per minute.” The other choices would be considered as being subjective data.

PTS: 1 DIF: Analysis REF: Types of Data

1. Which comment is appropriate for the nurse to make during the introduction stage of the assessment interview?

a.	It is almost time for me to leave. Do you have any questions for me?
b.	Describe your pain.
c.	I need to ask you a few questions about your health so we can better plan your care.
d.	Describe the number and characteristics of your bowel movements.

ANS: C

The introduction phase of the interview establishes the goals for the interaction and the nurse should begin with “I need to ask you a few questions about your health so we can better plan your care.” The comment “it is almost time for me to leave; do you have any questions for me?” would be for the nurse to say during the closure phase of the interview. The other two choices would be appropriate during the working phase of the interview.

PTS: 1 DIF: Application REF: Methods of Data Collection: Interview Stages

1. The nurse and client are in the working phase of the assessment interview. Which of the following is an example of a closed question?

a.	What is the reason for your visit today?
b.	Tell me about your family.
c.	What is your date of birth?
d.	What types of food do you prefer?

ANS: C

Closed questions are questions that can be answered briefly or with one-word responses. The choice that is a closed question would be “what is your date of birth?” The other choices are examples of open-ended questions or questions that encourage the client to elaborate about a particular concern or problem.

PTS: 1 DIF: Application REF: Methods of Data Collection: Interview

1. The nurse is beginning the health history within the nursing interview. This part of the assessment focuses on the:

a.	client’s functional health patterns before the current contact with a health care agency.
b.	symptoms of the disease.
c.	progression of the disease.
d.	prevention of disease processes.

ANS: A

The health history is a review of the client’s functional health patterns prior to the current contact with a health care agency. The symptoms of the disease would be reviewed during the review of systems and the reason for seeking health care. The progression of the disease would be addressed during the review of systems and the reason for seeking health care. Prevention of disease processes would be addressed during immunizations and exposure to communicable diseases.

PTS: 1 DIF: Application REF: Health History

1. Which of the following questions would the nurse use to obtain demographic information about a client?

a.	What is the reason for your visit today?
b.	Have you had any operations in the past?
c.	On a scale of 1 to 10, with 1 being poor and 10 being ideal, how would you rate your health?
d.	What is your name, address, and date of birth?

ANS: D

Demographic information includes personal data such as name, address, date of birth, gender, religion, race, ethnic origin, and occupation. “What is the reason for your visit today” would be asked during the reason for seeking health care. “Have you had any operations in the past” would be asked for previous illnesses, hospitalizations, and surgeries. “On a scale of 1 to 10” would be asked to rate the client’s health, and this question would be asked to assess the client’s perception of her health status.

PTS: 1 DIF: Application REF: Health History

1. The nurse notes ecchymotic areas on the client’s skin. This is an example of which physical examination technique?

a.	Inspection	c.	Percussion
b.	Palpation	d.	Auscultation

ANS: A

Inspection involves careful visual observation such as skin lesions and skin color. Palpation uses the sense of touch to assess texture, temperature, moisture, organ location, organ size, vibration, pulsations, masses, and tenderness. Percussion uses short tapping strokes on the surface of the skin to create vibrations of underlying organs. Auscultation involves listening to sounds in the body that are created by movement of air or fluid.

PTS: 1 DIF: Application REF: Physical Examination

1. The nurse, using the dorsal surface of the hand to detect a client’s temperature, is utilizing which of the following assessment techniques?

a.	Inspection	c.	Percussion
b.	Palpation	d.	Auscultation

ANS: B

Palpation uses the sense of touch to assess texture, temperature, moisture, organ location, organ size, vibration, pulsations, masses, and tenderness. Inspection involves careful visual observation such as skin lesions and skin color. Percussion uses short tapping strokes on the surface of the skin to create vibrations in underlying organs. Auscultation involves listening to sounds in the body that are created by movement of air or fluid.

PTS: 1 DIF: Application REF: Physical Examination

1. The nurse is using short, tapping strokes on the surface of the skin to create vibrations of underlying organs while assessing a client. This assessment technique would be considered to be:

a.	inspection.	c.	percussion.
b.	palpation.	d.	auscultation.

ANS: C

Percussion uses short tapping strokes on the surface of the skin to create vibrations of underlying organs. Inspection involves careful visual observation such as skin lesions and skin color. Palpation uses the sense of touch to assess texture, temperature, moisture, organ location, organ size, vibration, pulsations, masses, and tenderness. Auscultation involves listening to sounds in the body that are created by movement of air or fluid.

PTS: 1 DIF: Application REF: Physical Examination

1. The nurse is reviewing data for omissions or inconsistencies. This activity is considered as being:

a.	data collection.	c.	data organization.
b.	data verification.	d.	data clustering.

ANS: B

Data verification is the process through which data are validated as being complete and accurate, and ensuring no omissions or inconsistencies. Data collection occurs before data verification. Data organization and clustering occurs after data verification.

PTS: 1 DIF: Application REF: Data Verification

1. The nurse is going to assess a client according to a nursing assessment model. The model that the nurse would most likely NOT use would be:

a.	functional health patterns.	c.	Roy adaptation model
b.	theory of self-care.	d.	body systems model.

ANS: D

Nursing assessment models include functional health patterns, theory of self-care, and Roy’s adaptation model. The body systems model is often referred to as the “medical model,” and it is not a nursing model.

PTS: 1 DIF: Application REF: Assessment Models

1. The nurse is identifying a client’s needs according to Maslow’s theory. In this theory, client needs should be addressed in which of the following orders?

a.	Physiological, safety, love and belonging
b.	Safety, love and belonging, physical
c.	Self-esteem, physical, safety
d.	Love and belonging, self-actualization, self-esteem

ANS: A

Maslow’s theory identifies needs in the following order: physiologic needs, safety and security, need for love and belonging, self-esteem, and self-actualization.

PTS: 1 DIF: Application REF: Hierarchy of Needs

1. The nurse is working with the Minimum Data Set. This set was developed to:

a.	standardize care in outpatient clinics.
b.	set standards for Medicare/Medicaid reimbursements to hospitals.
c.	promote a comprehensive care plan for residents of Medicare/Medicaid-certified nursing homes.
d.	set standards for Medicare/Medicaid home health clinics.

ANS: C

The Minimum Data Set was developed by the Centers for Medicare and Medicaid Services to promote the development of a comprehensive care plan for every resident of Medicare- or Medicaid-certified nursing homes. The other choices are incorrect.

PTS: 1 DIF: Analysis REF: The Minimum Data Set (MDS)

1. The nurse assesses the vital signs of a client who comes to the clinic with vomiting and dehydration. This is an example of:

a.	assessment.	c.	planning.
b.	diagnosis.	d.	implementation.

ANS: A

The purpose of assessment is to establish a database concerning a client’s physical, psychosocial, and emotional health in order to identify health-promoting behaviors as well as actual and potential health problems. Diagnosis, planning, and implementation occur after the assessment.

PTS: 1 DIF: Analysis REF: Purpose of Assessment

1. The nurse is straining the client’s urine and measuring the output. Which should be recorded as objective data?

a.	The client complained of abdominal pain this morning.
b.	There were no stones in the client’s strained urine.
c.	The client said he didn’t see any stones in the urine.
d.	The client states, “It felt like I passed a stone.”

ANS: B

Objective data are measurable data that are obtained through observation, standard assessment techniques performed during the physical examination, and laboratory and diagnostic testing. The choice “There were no stones in the client’s strained urine” is an example of objective data. The other choices are subjective data.

PTS: 1 DIF: Application REF: Types of Data

1. In order to obtain the best information possible during the working phase of the assessment, the nurse should utilize which of the following questions?

a.	What has your doctor told you about your illness?
b.	You are really excited about the baby, aren’t you?
c.	Are you having pain right now?
d.	Do you eat three meals a day?

ANS: A

The nurse should ask an open-ended question in order to obtain the best information during the working phase of the assessment. The statement “you are really excited about the baby, aren’t you?” would not obtain information. The other two questions are closed questions and would not obtain the best information during the assessment.

PTS: 1 DIF: Application REF: Interview

1. The nurse is preparing to conduct a physical examination to obtain baseline measurements for a client. Baseline data collection is the:

a.	data collected when the client first came to the hospital.
b.	data collected by research that serves as a standard by which to compare the client’s data to determine if they meet the norms for their age and height.
c.	systematic organization of observations obtained during the physical examination that form the basis for comparison and evaluation to establish the status of a client at a given point in time.
d.	data collected and documented at the beginning of each hospitalized day and used to determine if there is a change in the client’s condition.

ANS: C

Baseline data collection is the systematic organization of observations obtained during the physical examination. The baseline becomes the basis for comparison and evaluation to establish the status of a client at a given point in time. The other choices are incorrect.

PTS: 1 DIF: Analysis REF: Physical Examination

1. The nurse is preparing to conduct a nursing history interview with a client. The focus of this interview is to obtain information about the:

a.	disease process that is causing the problems for the client.
b.	client’s perception of health–illness problems and responses to them.
c.	nursing interventions required for the client’s disease.
d.	goals for nursing care.

ANS: B

The nursing health history focuses on the client’s functional health patterns, responses to changes in health status, and alterations in lifestyle. The other choices do not describe the focus of the nursing history interview and are incorrect.

PTS: 1 DIF: Application REF: Health History

1. The nurse is assessing a client for pain. Which of the following statements is most likely to result in the most meaningful assessment data about pain?

a.	Where does the pain usually occur?
b.	Is the pain sharp or dull?
c.	What were you doing when the pain began?
d.	Describe the pain in your own words.

ANS: D

The statement “describe the pain in your own words” provides the opportunity for the client to talk about the pain. The other statements are actually closed questions and would not provide the most information about the client’s pain.

PTS: 1 DIF: Application REF: Interview Stages

1. The nurse would use which assessment method when examining the lungs of a client for abnormal sounds?

a.	Palpation	c.	Percussion
b.	Auscultation	d.	Inspection

ANS: B

Auscultation involves listening to sounds in the body that are created by movement of air or fluid. Areas most often auscultated include the lungs. Inspection involves visual observation. Palpation uses the sense of touch to assess texture, temperature, moisture, organ location, vibration, pulsations, masses, and tenderness. Percussion uses short tapping strokes on the surface of the skin to create vibrations in underlying organs.

PTS: 1 DIF: Application REF: Physical Examination

1. The nurse is completing the documentation on a minimum data set form. This type of documentation:

a.	is used solely for documenting comprehensive assessments in certified nursing homes.
b.	uses checklists to facilitate documentation by summarizing findings in abbreviated forms.
c.	uses a narrative format to allow nurses flexibility in recording their findings.
d.	focuses directly on assessment needs for a particular service provided.

ANS: A

The Minimum Data Set (MDS) was developed by the Centers for Medicare and Medicaid Services to promote the development of a comprehensive care plan for every resident of Medicare- or Medicaid-certified nursing homes. The other choices are incorrect and do not describe the minimum data set.

PTS: 1 DIF: Application REF: The Minimum Data Set (MDS)

1. The nurse is beginning a nursing interview with a client. The primary purpose of the introduction phase of the nursing interview is to:

a.	focus on details of data collection.
b.	collect biographical data first before asking more personal information.
c.	establish the goals for the interaction.
d.	allow validation of perceptions with the client.

ANS: C

The introduction stage of the interview establishes the goals for the interaction. The primary goal of the assessment interview is the collection of data about the client. Biographical information is collected during the demographic information phase of the health history. Validation of perceptions is done with the client during the closure stage of the nursing interview.

PTS: 1 DIF: Analysis REF: Methods of Data Collection

1. Which of the following should the nurse do before identifying nursing diagnoses for a client?

a.	Verify data	c.	Interpret data
b.	Organize data	d.	Document data

ANS: C

Data interpretation is necessary for identification of nursing diagnoses. Verification of data occurs after data collection. Organization of data occurs after verification. Documentation of data occurs after interpreting the data.

PTS: 1 DIF: Application REF: Data Interpretation

1. The nurse is documenting on a client’s medical record. This documentation should include the:

a.	name of the physician.	c.	client’s opinion of the meals.
b.	name of the client’s spouse.	d.	data to support problems and diagnoses.

ANS: D

Documentation is the basis for determining quality of care and should include appropriate data to support identified problems and diagnoses. The other choices are incorrect and should not be included in the documentation.

PTS: 1 DIF: Application REF: Data Documentation

1. The nurse is writing a narrative description of observations in a client’s medical record. This type of assessment format is considered as being a(n):

a.	checklist.	c.	open-ended format.
b.	specialty format.	d.	minimum data set format.

ANS: C

The open-ended format for documentation allows the nurse to write a narrative description of observations. The checklist format facilitates documentation by summarizing findings in an abbreviated form. A specialty format supports documentation from a specialty area such as outpatient surgery. The minimum data set is used for residents of a Medicare- or Medicaid-certified nursing home.

PTS: 1 DIF: Application REF: Types of Assessment Formats

1. The nurse is unable to elicit assessment information from a client. Which of the following should the nurse do?

a.	Talk with the client’s family.
b.	Document “unable to obtain” on the assessment form.
c.	Leave the form for the next nurse to complete.
d.	Document information while the physician does the admission physical.

ANS: A

The client should always be considered as the primary source of information; however, if the client is unable or unwilling to give information, the client’s family can be talked to as sources of valuable information. The nurse should not document “unable to obtain” on the assessment form nor should the nurse leave the form for the next nurse to complete. The nurse should not document nursing assessment information while the physician does the admission physical.

PTS: 1 DIF: Application REF: Sources of Data

1. The nurse is completing a current list of medications with a client. Which of the following should be included in this list?

a.	Amount of exercise performed each day	c.	Normal sleeping pattern
b.	Current weight	d.	Use of herbal preparations

ANS: D

All medications including prescription and over-the-counter are to be recorded by name, frequency, and dosage. This information should include laxatives, birth control pills, nonprescription pain relief medications, and herbal preparations. The amount of exercise, current weight, and normal sleeping patterns are not documented on the current medications portion of the health history.

PTS: 1 DIF: Application REF: Health History

CHAPTER 7: NURSING DIAGNOSIS

MULTIPLE CHOICE

1. The nurse is identifying a wellness diagnosis for a client. Which of the following is an example of this type of diagnosis?

a.	Fluid volume deficit related to frequent, loose stools
b.	Risk for fluid volume overload due to IV infusion
c.	Potential for enhanced spiritual well-being
d.	Rape trauma syndrome

ANS: C

Well diagnoses identify the condition or state of being healthy that may be enhanced by deliberate health-promoting activities. An example of this type of diagnosis is “Potential for enhanced spiritual well-being.” The other choices are not examples of wellness diagnoses and are incorrect.

PTS: 1 DIF: Analysis REF: Categories of Nursing Diagnoses

1. The nurse is planning nursing diagnoses for a client. Which statement is true regarding nursing diagnoses?

a.	Nursing diagnoses are very similar to medical diagnoses.
b.	A nursing diagnosis identifies a specific disease or condition.
c.	A nursing diagnosis focuses on the client’s responses to health problems.
d.	Nursing diagnoses are used as a mechanism for direct financial reimbursement.

ANS: C

Nursing diagnosis is unique in that it focuses on a client’s response to a health problem rather than on the problem itself, and it provides the structure through which nursing care can be delivered. Nursing diagnoses are not similar to medical diagnoses nor do they identify a specific disease or condition. Nursing diagnoses are not used as a mechanism for direct financial reimbursement.

PTS: 1 DIF: Analysis REF: Purposes of Nursing Diagnoses

1. The nurse is writing a two-part nursing diagnosis statement. The second component of a two-part nursing diagnosis is the:

a.	problem statement.	c.	defining characteristics.
b.	etiology.	d.	signs and symptoms.

ANS: B

The components of a two-part nursing diagnosis statement are the problem statement, or diagnostic label, and etiology. The problem statement is the first part. Defining characteristics or signs and symptoms are provided in a three-part nursing diagnosis statement.

PTS: 1 DIF: Application

REF: The Two-Part Statement| The Three-Part Statement

1. Which of the following is a correctly stated nursing diagnosis?

a.	Strep throat related to bacteria
b.	Skin breakdown due to wet bed
c.	Myocardial infarction related to ischemia of the muscle
d.	Altered nutrition, less than body requirements, related to difficulty swallowing

ANS: D

“Altered nutrition, less than body requirements, related to difficulty swallowing” is the correctly written nursing diagnosis. “Strep throat related to bacteria” and “Myocardial infarction related to ischemia of the muscle” both contain medical diagnoses and are incorrect. “Skin breakdown due to wet bed” is inappropriate and incorrect.

PTS: 1 DIF: Analysis REF: The Two-Part Statement

1. The nurse has written nursing diagnoses for a client’s care. Which of the following is a correctly stated nursing diagnosis?

a.	Impaired bowel elimination related to long-term laxative use
b.	Infectious mononucleosis caused by Epstein-Barr virus
c.	Ineffective airway clearance related to pneumonia
d.	Impaired skin integrity related to nurse aide not turning client

ANS: A

Impaired bowel elimination related to long-term laxative use is the correctly written nursing diagnoses. Infectious mononucleosis and Ineffective airway clearance both include a medical diagnosis in the statement. Impaired skin integrity has an inappropriate etiology.

PTS: 1 DIF: Analysis

REF: The Two-Part Statement| Incorrect Writing of the Nursing Diagnosis Statement

1. The nurse is having difficulty developing nursing diagnoses for a client because of incomplete assessment data. A problem with assessment data may be that the:

a.	data is comprehensive.
b.	client may be unwilling to share data.
c.	complete validation is needed.
d.	nursing diagnosis is clear.

ANS: B

Restricted data collection occurs when a client is unable or unwilling to provide the necessary data. This can lead to errors in judgment and incorrect nursing diagnoses identification. Comprehensive data would cause appropriate nursing diagnoses identification. Validation would occur after the data is collected. A clear nursing diagnosis is contingent upon complete data.

PTS: 1 DIF: Application REF: Assessment Errors

1. The nurse is planning to develop nursing diagnoses for a client. The process of developing a nursing diagnosis includes:

a.	data collection, interpretation, and clustering of assessment cues.
b.	observation, auscultation, palpation, and percussion.
c.	comparing client responses against the expected outcomes.
d.	evaluating lab data against standards and norms.

ANS: A

The development of nursing diagnoses is a systematic process that includes the activities of data collection, data interpretation, and clustering assessment cues. The other choices are not activities conducted while developing nursing diagnoses and are incorrect.

PTS: 1 DIF: Application REF: Nursing Checklist: Developing Nursing Diagnoses

1. The nurse is determining if a recurring client problem could be considered for a nursing diagnosis. The organization that develops and approves nursing diagnoses is the:

a.	ANA.	c.	AMA.
b.	NANDA.	d.	TJC.

ANS: B

The North American Nursing Diagnosis Association or NANDA is the organization that develops and approves nursing diagnoses. The American Nurses Association or ANA has a policy statement that endorses the use of nursing diagnoses. The American Medical Association or AMA does not participate in the development of nursing diagnoses. The Joint Commission or TJC does not participate in the development of nursing diagnoses.

PTS: 1 DIF: Application REF: Historical Perspective

1. The nurse is making inferences about patterns of data collected from a client. In which step of the nursing process is the nurse currently working?

a.	Assessing	c.	Planning
b.	Diagnosing	d.	Implementing

ANS: B

Nursing diagnoses is the second step of the nursing process and includes clinical judgments made about the wellness states, illness states and syndromes, and the readiness to enhance current states of wellness experienced by the client. The clinical judgment is based on a critical analysis of the assessment data. The nurse is working within the nursing diagnosis phase of the nursing process. Collecting data would occur during the assessment phase. Identifying goals and outcomes would occur during the planning phase. Providing client interventions would occur during the implementing phase.

PTS: 1 DIF: Application REF: Introduction

1. The nurse is planning to assess a client who is newly admitted with heart failure. Which best describes how the nursing process differs from the medical process?

a.	The nursing process requires interpersonal, technical, and intellectual skills.
b.	The nursing process focuses on the client’s responses to illness or injury.
c.	The nursing process focuses on identifying the client’s disease process.
d.	The nursing process is not limited to use with hospitalized clients.

ANS: B

The nursing process focuses on the human response to responses to illness or injury. Both the nursing and medical process require interpersonal, technical, and intellectual skills. The medical process focuses on identifying the client’s disease process. Both the nursing and medical processes are not limited to use with hospitalized clients.

PTS: 1 DIF: Analysis REF: Comparison of Nursing and Medical Diagnoses

1. A client is admitted with cellulitis of the left leg. The nurse develops a nursing diagnosis of Acute pain related to tissue injury and inflammation, as evidenced by redness, swelling, and complaint of pain at 7 on the 0–10 pain scale. A characteristic defining this nursing diagnosis is:

a.	tissue injury.
b.	inflammation.
c.	cellulitis.
d.	complaint of pain at 7 on scale of 0–10.

ANS: D

The defining characteristics within the nursing diagnosis are observable manifestations of the diagnosis. In this case it would be the client’s complaint of pain which is identified as being 7 on the pain scale. Even though pain cannot be observed, the client has placed a value on the severity of the pain. Tissue injury, inflammation, and cellulitis are all causing the client pain and may or may not be observed.

PTS: 1 DIF: Analysis REF: Components of a Nursing Diagnosis

1. The nurse diagnoses the client’s health problem as Altered elimination. Which information from the database would be an appropriate etiology for this diagnosis?

a.	Complaints of cramping and constipation
b.	Diagnosis of hip fracture
c.	Poor fiber intake
d.	Abdominal distention

ANS: C

When writing a two-part statement, the diagnostic label is linked to the etiology or that which is related to or causing the problem. In this case, the etiology would be poor fiber intake. Complaints of cramping and constipation are assessment data about the problem. Diagnosis of hip fracture is a medical diagnosis. Abdominal distention is assessment data related to the problem.

PTS: 1 DIF: Application REF: The Two-Part Statement

1. The nurse is documenting client care into the computerized clinical documentation system. Point-of-care computing and clinical decision support are:

a.	part of the diagnostic-related group reimbursement system.
b.	a mechanism for obtaining direct reimbursement of nursing care.
c.	part of the systematized nomenclature of medicine.
d.	two ways nursing informatics is improving safety of client care.

ANS: D

Point-of-care computing and clinical decision support are two ways that nursing informatics are improving the safety of client care while making documentation of care more efficient for nurses. Point-of-care computing and clinical decision support are not a part of the diagnostic-related group reimbursement system nor are they mechanisms for nursing care to be directly reimbursed. They are also not a part of the systematized nomenclature of medicine.

PTS: 1 DIF: Analysis REF: Nursing Diagnoses and Nursing Informatics

1. The nurse is preparing to write nursing diagnoses for a client. The five components of a nursing diagnosis that the nurse should include are:

a.	assessment, diagnosis, planning, implementation, evaluation.
b.	diagnostic label, definition, defining characteristic, risk factors, related factors.
c.	actual problem, potential problem, possible problem, etiology, risk factor.
d.	purpose, goals, interventions, evaluations, client responses.

ANS: B

The five components of a nursing diagnosis are diagnostic label, definition, defining characteristics, risk factors, and related factors. The other choices are not components of a nursing diagnoses and are incorrect.

PTS: 1 DIF: Application REF: Components of a Nursing Diagnosis

1. A client asks why the nurse is creating nursing diagnoses for her care when her physician has already told her what her medical problems are. The nurse should respond that “nursing diagnoses:

a.	provide the framework for nursing care.”
b.	provide a mechanism for reimbursement for nursing care.”
c.	provide labels for diagnosis-related groups.”
d.	include the medical diagnosis.”

ANS: A

Nursing diagnoses are unique in that they focus on a client’s response to a health problem and provide the structure to deliver nursing care. Nursing diagnoses do not provide a mechanism for reimbursement for nursing care nor do they provide labels for diagnostic-related groups. Nursing diagnoses do not include the medical diagnosis.

PTS: 1 DIF: Application REF: Purposes of Nursing Diagnoses

1. The nurse is considering an actual nursing diagnosis for a client. An actual nursing diagnosis category can be applied when:

a.	risk factors exist that may cause a problem.
b.	the state of being healthy may be enhanced by nursing actions.
c.	signs and symptoms are identified that define an existing problem.
d.	the nurse thinks the client is ill.

ANS: C

Actual diagnoses are those that are already in existence with signs and symptoms identified that define the problem. Risk factors that exist would be appropriate for a risk diagnosis. The state of being healthy, which may be enhanced by nursing actions, would be a wellness diagnosis. There is not category of nursing diagnosis to support the nurse thinking the client is ill.

PTS: 1 DIF: Application REF: Categories of Nursing Diagnoses

1. The nurse is considering a risk diagnosis for a client. A risk diagnosis can be applied when:

a.	there is a recognized vulnerability to exhibit a problem, but the response has not manifested itself.
b.	the state of being healthy may be enhanced by nursing interventions with the individual.
c.	signs and symptoms are identified that define an existing problem.
d.	the client indicates a desire to increase well-being.

ANS: A

Risk diagnoses are identified when there is a recognized vulnerability for the client to exhibit a problem but, the response has not yet manifested. Well diagnoses are identified when the state of being healthy may be enhanced by nursing interventions with the client. Actual diagnoses are identified when the signs and symptoms exist for a problem. Health promotion diagnoses are identified when the client indicates a desire to increase well-being.

PTS: 1 DIF: Application REF: Categories of Nursing Diagnoses

1. The nurse is identifying the domain in which to select a nursing diagnosis for a client. Which of the following is NOT included in the 13 domains of NANDA-approved nursing diagnoses?

a.	Coping/stress tolerance	c.	Infection
b.	Safety/protection	d.	Elimination/exchange

ANS: C

There are 13 domains of NANDA-approved nursing diagnoses. Coping/stress tolerance, safety/protection, and elimination/exchange are all domains. Infection is not a domain.

PTS: 1 DIF: Application REF: Taxonomy of Nursing Diagnoses

1. Which of the following reasons would explain why a nurse would inappropriately cluster data?

a.	The nurse relies on the NANDA-approved list of nursing diagnoses.
b.	The nurse lacks sufficient theoretical and clinical expertise and knowledge.
c.	The nurse uses a standardized assessment tool to collect data.
d.	The nurse groups data cues that relate to each other.

ANS: B

Inappropriate data clustering may occur when the nurse lacks sufficient theoretical and clinical expertise in order to appropriately cluster data cues. Relying on the NANDA-approved list of nursing diagnoses would not cause the nurse to inappropriately cluster data. Using a standardized assessment tool would not cause the nurse to inappropriately cluster data. Grouping data cues that relate to each other is the correct way to cluster data.

PTS: 1 DIF: Analysis REF: Diagnostic Errors

1. The nurse is writing nursing diagnoses statements for a client. Which of the following nursing diagnosis statement is correctly written?

a.	Imbalanced nutrition: Less than body requirements RT renal disease
b.	Acute pain RT to hysterectomy
c.	Imbalanced nutrition: Less than body requirements RT inadequate intake
d.	Body image disturbance due to anorexia

ANS: C

“Imbalanced nutrition: Less than body requirements RT inadequate intake” is the one statement that is written correctly since it contains all of the requirement parts. The other choices include medical diagnoses and are incorrect.

PTS: 1 DIF: Analysis

REF: The Two-Part Statement| Incorrect Writing of the Nursing Diagnosis Statement

1. To avoid committing errors in the nursing diagnostic process, the nurse should:

a.	limit the amount of assessment data.
b.	assure that interpretation of data is based on nursing and not on the medical diagnoses.
c.	consult with a physician to make sure they are interpreting data correctly.
d.	compare the data collected with a medical diagnostic resource.

ANS: B

To develop the best nursing diagnoses for a client, the nurse should assure that the interpretation of the data is based on nursing and not on the medical diagnoses. Limiting the amount of assessment data would not help to avoid errors. The nurse does not need to consult with a physician nor compare the data with medical diagnostic resources prior to developing nursing diagnoses.

PTS: 1 DIF: Application

REF: Incorrect Writing of the Nursing Diagnosis Statement| Nursing Checklist: Avoiding Common Diagnostic Errors

1. The nurse has written the nursing diagnostic statement, “Risk for impaired skin integrity related to malnutrition.” What is the risk factor in this statement?

a.	Impaired skin integrity	c.	Immobility
b.	Malnutrition	d.	Alteration in nutrition

ANS: B

Risk factors are those elements that increase the chances of a client being susceptible to a disease state or life event that will have an impact on health. For this diagnostic statement, the risk factor would be malnutrition. Impaired skin integrity would be an outcome because of malnutrition. Immobility and Alteration in Nutrition are diagnostic labels.

PTS: 1 DIF: Analysis REF: Components of a Nursing Diagnosis

1. The nurse is having difficulty with developing appropriate nursing diagnoses for a client’s care. Which of the following could explain why this nurse is having difficulty?

a.	Diagnosing is for the physician to do.	c.	Other nurses think it is a waste of time.
b.	The client has too many health issues.	d.	The nurse cannot find the diagnostic label appropriate for the client’s needs.

ANS: D

Limitations and professional concerns are associated with nursing diagnosis. The primary concern is the lack of consensus among nurses regarding the list, and that the list does not contain the diagnosis needed for a client. Difficulty in creating nursing diagnoses is not because diagnosing is for the physician to do or that the client has too many health issues. Nurses who think nursing diagnoses is a waste of time might be unfamiliar with the list and would benefit from additional education.

PTS: 1 DIF: Analysis REF: Limitations of Nursing Diagnosis

1. The nurse, unable to locate a nursing diagnosis appropriate for a client, is describing the phenomena as accurately as possible. This nurse could also do which of the following?

a.	Skip over this particular client problem.
b.	Incorporate the problem with another applicable nursing diagnosis.
c.	Share the discovery with NANDA.
d.	Ask the nurse manager to come up with an appropriate nursing diagnosis.

ANS: C

When a nurse encounters a situation that does not fit into nursing diagnosis language, the nurse should describe the observed phenomena. Then the nurse should share the identified need with NANDA so the nursing diagnosis language will grow and become more usable for nurses in practice. The nurse should not skip over the client’s problem or incorporate the problem with another applicable nursing diagnosis. The nurse should not ask the nurse manager to identify the nursing diagnosis.

PTS: 1 DIF: Application REF: Overcoming Barriers to Nursing Diagnosis

1. The spouse of an elderly ill client tells the nurse that he is exhausted with providing care for the client at home and needs a break. An appropriate nursing diagnosis for the spouse would be:

a.	Grieving.	c.	Decisional conflict.
b.	Caregiver role strain.	d.	Home maintenance.

ANS: B

The nursing diagnosis that would be most applicable for the client’s spouse would be Caregiver role strain. The other choices do not reflect the spouse’s exhaustion with providing care to the ill client at home and are incorrect.

PTS: 1 DIF: Application REF: Table 7-2 Nursing Diagnoses

1. The nurse is determining the best nursing diagnosis for a client. The component of the nursing diagnosis that differentiates one diagnosis from another is considered:

a.	diagnostic label.	c.	defining characteristics.
b.	definition.	d.	related factors.

ANS: B

The definition provides a clear description and differentiates one diagnosis from another. The diagnostic label consists of one or more nouns that name the diagnosis and can be a word or a phrase that describes the pattern or related cues. Defining characteristics are observable manifestations of the diagnosis. Related factors can precede, be associated with, contribute to, or be related to the nursing diagnosis.

PTS: 1 DIF: Analysis REF: Components of a Nursing Diagnosis

1. The nurse is developing a wellness diagnosis for a client. The nurse should write this diagnosis as a:

a.	one-part statement.	c.	three-part statement.
b.	two-part statement.	d.	four-part statement.

ANS: A

A wellness diagnosis should be written as a one-part statement because the wellness condition is not related to anything, has no etiology, and has no defining characteristics. The wellness diagnosis should not be written as a two-part or three-part statement. There is no four-part nursing diagnosis statement.

PTS: 1 DIF: Application

REF: Table 7-1 Comparison of One-, Two-, and Three-Part Nursing Diagnosis Statements

1. The nurse is reviewing data collected from a client for cues. How should the nurse use critical thinking skills when analyzing the cues?

a.	Select interventions.
b.	Plan for the client’s discharge.
c.	Identify any patterns.
d.	Determine which information is true or incorrect.

ANS: C

Critical thinking skills are used when analyzing collected data for cues. The data should be analyzed for patterns and natural informational groupings. Critical thinking skills are not used to select interventions at this time nor to plan for the client’s discharge. The nurse should not analyze the data to determine which information is true or incorrect.

PTS: 1 DIF: Application REF: Interpreting Cues

1. A client’s chest x-ray shows significant left lung consolidation; however, the client is not short of breath nor is she experiencing any other respiratory symptoms. What should the nurse do with the information obtained from the chest x-ray?

a.	Plan pulmonary toileting activities for the client.
b.	Collect more data and analyze for appropriate cues.
c.	Prepare the client for emergency respiratory care.
d.	Ask the physician if the client would benefit from a chest tube.

ANS: B

Conclusions should not be drawn from one piece of data. The client has lung consolidation; however, she is not demonstrating any signs of respiratory distress. The nurse should assess the client further regarding the lung consolidation in an effort to identify more cues. The nurse should not plan pulmonary toileting activities nor prepare the client for emergency respiratory care. The nurse should not ask the physician if the client would benefit from a chest tube.

PTS: 1 DIF: Application REF: Clustering Cues

1. A client was admitted for fluid volume overload. Over the course of several days, the client is progressively becoming more lethargic and the client is sleeping throughout the day. The nurse contacts the physician to report neurological changes. When the family arrives, they ask if the patient has been using a machine for sleep apnea. What does this situation suggest to the nurse?

a.	The patient does not have sleep apnea.
b.	The patient did not have a complete assessment done.
c.	The client’s fluid volume overload is causing pulmonary edema.
d.	The physician did not communicate that the client has sleep apnea.

ANS: B

This situation is an example of an incomplete assessment. If the client were assessed for sleep–rest patterns, the nurse would have been informed of the client’s sleep apnea and would have planned accordingly. This situation does not suggest that the client does not have sleep apnea. There is not enough information to determine if the client has pulmonary edema. It is possible that the hospital physician was unaware of the client’s sleep apnea.

PTS: 1 DIF: Analysis REF: Assessment Errors