Nursing Diagnosis Practice Exam

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Text Mode

Text version of the exam.

1. After completion of the client assessment, the nurse uses nursing diagnoses because they

  1. Make all client problems become more quickly and easily resolved
  2. Assist the nurse to distinguish medical from nursing problems
  3. Are required for accreditation purposes
  4. Identify the domain and focus of nursing

2. A 53-year-old client is seen at the clinic for a yearly physical examination. In evaluating the client’s weight, the nurse also considers the age and height. This is an example of:

  1. Defining the client problem
  2. Recognizing gaps in data assessment
  3. Comparing data with normal health patterns
  4. Drawing conclusions about the client’s response

3. Nursing diagnoses meet specific criteria so they accurately reflect both the client’s problem and the possible etiology involved. Of the following statements, which one is an example of an appropriately written nursing diagnosis?

  1. Acute pain related to left mastectomy
  2. Impaired gas exchange related to altered blood gases
  3. Deficient knowledge related to need for cardiac catheterization
  4. Need for high protein diet related to alteration in nutrition

4. Nursing diagnoses meet specific criteria so they accurately reflect both the client’s problem and the possible etiology involved. Of the following statements, which one is an example of an appropriately written nursing diagnosis?

  1. Cardiac output decreased related to motor vehicle accident
  2. Potential for injury related to improper teaching in the use of crutches
  3. Ineffective airway clearance related to increased secretions
  4. Risk for change in body image related to cancer

5. The nurse has diagnosed the client’s problem as altered elimination. From the data base the nurse identifies all the following as appropriate etiologies for this diagnosis except:

  1. Poor fiber intake
  2. Limited fluid intake
  3. Total hip replacement
  4. Lower abdominal discomfort

6. The nurse is concerned that atelectasis may develop as a postoperative complication. Which of the following is an appropriate diagnostic label for this problem should it occur?

  1. Ineffective airway clearance
  2. Impaired gas exchange
  3. Decreased cardiac output
  4. Impaired spontaneous ventilation

7. The nurse recognizes that which one of the following statements is true with regard to the formulation of nursing diagnoses?

  1. The etiology of the diagnosis must be within the scope of the health care team’s practice.
  2. The diagnosis must remain constant during the client’s hospitalization.
  3. The diagnosis should include the problem and the related contributing conditions.
  4. The diagnosis should identify a “cause and effect” relation.

8. When completing a client assessment and determining nursing diagnoses, the nurse may make an error. A diagnostic error can influence the application of the nursing care plan. A likely source for a nursing diagnosis error is if the nurse:

  1. Validates the assessment information in the data base
  2. Uses the North American Nursing Diagnosis Association (NANDA) list of diagnoses as a source
  3. Formulates a diagnosis too closely resembling a medical diagnosis
  4. Distinguishes the nursing focus instead of other health care disciplines

9. Identify the defining characteristics in the following nursing diagnosis: Altered speech related to recent neurological disturbance, as evidenced by inability to speak in complete sentences:

  1. “Altered speech”
  2. “As evidenced by”
  3. “Recent neurological disturbances”
  4. “Inability to speak in complete sentences”

10. The nurse recognizes that the primary purpose of a nursing diagnosis is to:

  1. Support the medical plan of care
  2. Provide a standardized approach for all clients
  3. Recognize the client’s response to an illness or situation
  4. Offer the nurse’s subjective view of the client’s behaviors
Answers and Rationale
  1. Answer D. After completing the client assessment, the nurse develops nursing diagnoses based on the data obtained. Nursing diagnoses distinguish the nurse’s role from that of the physician, and help nurses to focus on the role of nursing in client care.
  2. Answer C. The nurse used scientific knowledge and experience to analyze and interpret data collected about the client. This includes comparing the data with norms.
  3. Answer C. This nursing diagnosis is written correctly. It defines a problem and its possible cause; in this case, the problem is the client’s response to a diagnostic test.
  4. Answer C. This nursing diagnosis is written appropriately. It identifies a problem by using a NANDA International diagnostic statement and connects it to its etiology.
  5. Answer C. Because the medical diagnosis requires medical interventions, it is legally inadvisable to use it in the nursing diagnosis. Rather, the nurse should identify the client’s response, such as decreased mobility. The nurse should be able to provide nursing interventions that will treat the etiology.
  6. Answer B. A potential etiology for impaired gas exchange may be atelectasis.
  7. Answer C. This is a true statement. Related factors are causative or other contributing factors that have influence the client’s actual or potential response to the health problem and can be changed by nursing interventions.
  8. Answer C. A nursing diagnosis should identify the client’s response, not the medical diagnosis. Because the medical diagnosis requires medical interventions, it is legally inadvisable to include it in the nursing diagnosis.
  9. Answer D. Defining characteristics are assessment findings that support the nursing diagnosis. In this example, the inability to speak in complete sentences supports the nursing diagnosis of altered speech.
  10. Answer C. The primary purpose of a nursing diagnosis is to recognize the client’s response to an illness or situation. The nurse can then use the nursing diagnosis to select appropriate nursing interventions to achieve positive client outcomes.
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