Prep U 16-20

Which is the best example of a nursing diagnosis?

Ineffective Breastfeeding related to latching as evidenced by nonsustained suckling at the breast.

The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action?

Notify the health care provider for additional orders.

A client recently diagnosed with pancreatic cancer tells the nurse, "I don't see any hope for my future." What would be the most appropriate nursing diagnosis for the nurse to formulate to address this health problem?

Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis

After completing a client abdominal assessment, the nurse finds diminished bowel sounds. To determine what intervention is needed, which step would the nurse take first?

Review the client's recent food and fluid intake.

A nurse, who is caring for a client admitted to the patient care unit with acute abdominal pain, formulates the care plan for the client. Which nursing diagnosis is the priority for this client?

Impaired Comfort

Which nursing actions would take place during the diagnosis stage of the nursing process? Select all that apply.

The nurse asks, "Based on what you have told me, it seems that urinary incontinence is a problem for you. What do you think?"

The nurse identifies that the client has effectively coped with health stressors in the past.

The nurse identifies that the client who is on strict bed rest is at risk for impaired skin integrity.

The nurse determines that the client needs to have a decrease in activity.

Assessment of a client with difficulty breathing reveals that the client has thick, tenacious secretions in the trachea and bronchi and excessive sputum with coughing. The respiratory rate is slightly increased. When developing this client's plan of care, which intervention would the nurse include?

Tracheobronchial suctioning

Which example of client care is not the responsibility of the nurse?

Confirming a medical diagnosis

A client has been diagnosed with a recent myocardial infarction. What collaborative problem would be the priority for the nurse to address?

PC: Decreased Cardiac Output related to cardiac tissue damage

After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type?

Actual

Which describes the best approach for the development of nursing diagnoses?

Develop nursing diagnoses from clusters of significant data.

Which factor is most likely to contribute to the nurse making a diagnostic error?

The client withholds information during the client assessment.

The nurse is aware that nursing diagnoses are:

within the nursing scope of practice to develop and client-focused.

The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this infant, but I have always believed that abortion is a sin. I don't know what to do." What nursing diagnosis would be most appropriate for the nurse to formulate?

Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement

A nurse documents the following nursing diagnosis on a client's plan of care: "Readiness for Enhanced Breast-Feeding." The nurse has identified which type of nursing diagnosis?

Health promotion

A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify

Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor

Which component of a nursing diagnosis gives additional meaning to the nursing diagnosis?

Descriptors

A client reports not having a bowel movement for 7 days, followed by a day of small, loose stools. How does the nurse define the health problem?

Constipation related to irregular evacuation patterns

The nurse recognizes that health problems that the nurse can address by independent nursing interventions are called:

actual or potential nursing diagnoses.

What association meets every 2 years to further progress in defining, classifying, and describing nursing diagnoses?

NANDA-International (NANDA-I)

During morning report, the night nurse tells the day nurse that the client refused to allow the technician to draw blood for laboratory testing. What step would be essential for the day nurse to complete before selecting a nursing diagnosis to address this issue?

The nurse should determine the reason for the client's refusal.

A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern?

Risk for Community Contamination related to possible environmental pollution

The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping?

Health promotion nursing diagnosis

The nurse is developing and documenting a nursing diagnosis for a client. When formulating the nursing diagnosis, what guidelines should the nurse follow?

Use accepted terms for the specific facility.

A client admitted for a surgical procedure tells the nurse, "I am very worried because I am allergic to latex. I want to make sure that everyone knows this." To ensure the safety of the client, which nursing diagnosis should the nurse assign to this client and address in the care plan?

Risk for Allergy Response related to latex allergy

The nurse is caring for a hospitalized client. The nurse explains to the client that a care plan will be used for which reason(s)? Select all that apply.

to improve the communication between nurses about the client's care needs

to revise the care provided when planned interventions are not effective

to ensure that the client is involved in decision making about care

A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination?

Bowel Incontinence

A nurse is explaining the purpose of nursing diagnoses to a client. What would be the most appropriate statement for the nurse to make?

"Nursing diagnoses are used to guide the nurse in selecting appropriate nursing interventions."

The nurse has selected a nursing diagnosis of "Impaired Home Maintenance" for an older adult client. What assessment data would evidence this diagnosis?

The nurse observes unsafe conditions in the client's home.

A pregnant client asks the nurse for information on breastfeeding. What type of nursing diagnosis should the nurse formulate?

A health promotion nursing diagnosis

A nurse documents the following nursing diagnosis on a client's plan of care: "Fluid Volume Deficit related to gastrointestinal upset from food poisoning as evidenced by vomiting and diarrhea for the past three days, slow skin turgor, and weight loss." The nurse identifies which part of the statement as the etiology?

Gastrointestinal upset from food poisoning

A nurse makes a nursing diagnosis of Constipation after a client reports not defecating on the last trip to the bathroom. The nurse has no other information on the client's defecation history. This is an example of:

premature closure.

The care plan for a client who has been frequently admitted to the hospital for exacerbation of chronic obstructive pulmonary disease (COPD) includes a nursing diagnosis of "Noncompliance related to lack of knowledge as evidenced by frequent admissions to the hospital." What is the most appropriate method for the nurse to use to validate the nursing diagnosis?

Assess the client's knowledge of COPD.

The nurse is assessing a 3-week-old infant who has not gained weight since birth. The infant's bowel sounds are present in all quadrants and breath sounds are clear to auscultation. The infant's parent reports that the infant cries much of the night but sleeps better in the daytime. The parent reports that the child only breastfeeds about four times in a 24-hour period and that the parent does not seem to have much milk. Which nursing concern is the priority for this parent-infant dyad?

altered breastfeeding

Which is a legal responsibility of a nurse who has documented a nursing diagnosis related to a client's kidney failure?

Reporting signs and symptoms related to the client's kidney failure

A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis?

Ineffective Airway Clearance

"Acute related to instillation Pain of peritoneal dialysate as evidenced by client wincing and grimacing during procedure, client description of experience as 'stabbing'" is an example of which type of nursing diagnosis?

Actual nursing diagnosis

The nurse is formulating nursing diagnoses pertaining to a client with pancreatic cancer. Which factors should the nurse identify as strengths of the client? Select all that apply.

The client has been accompanied by family members to every appointment.

The client states a belief in a reward in heaven after death.

The client has demonstrated effective coping skills in the past.

A community group has requested the public health nurse to present a program describing the advised schedule of immunizations for children. To plan for this program, what nursing diagnosis would be most appropriate for the nurse to select?

Readiness for Enhanced Knowledge: Childhood Immunizations

When used in a nursing diagnosis, the descriptor "impaired" has which meaning?

Weakened or damaged

A client undergoing chemotherapy for breast cancer has lost all hair. The client states, "I cannot stand to see myself without hair. I am disgusting." What would be the most appropriate nursing diagnosis for the nurse to use to address this client's problem?

Disturbed Body Image related to loss of hair

The formulation of nursing diagnoses is unique to the nursing profession. Which statement accurately represents a characteristic of diagnosing?

Nurses write nursing diagnoses to describe client problems that nurses can treat.

A client has been admitted to a hospital due to an acute psychotic episode. Which assessment data would the nurse identify as this client's strengths? Select all that apply.

The client has ample financial resources.

The client is willing to attend counseling sessions.

An older adult client's venous ulcer has become foul-smelling after the client began using strips of a sheet to dress the wound due to running out of sterile dressing supplies. How should the nurse document a nursing diagnosis statement related to this client's circumstances?

Risk for Infection related to knowledge deficit

A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify?

Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor

Which nursing diagnosis is written incorrectly as a result of the health problem and etiology being reversed?

Prolonged Immobility related to impaired skin integrity

A nurse is educating a client about care to be taken in nephrotic syndrome. The client expresses that the education is of no use because the disease is not curable. What nursing diagnosis should the nurse formulate with regard to the client's concern?

Risk for Powerlessness

While caring for a client admitted with a Clostridium difficile infection, the nurse notes that the client has had three loose bowel movements in 3 hours. What would be the most appropriate nursing diagnosis to address this health problem?

Diarrhea related to infectious process as evidenced by three loose bowel movements in 3 hours

A nurse is using Gordon's functional health patterns as an organizing framework for client assessment. The client has significant problems related to breathing, for which the nurse identifies several nursing diagnostic labels, including Ineffective Breathing Pattern and Impaired Gas Exchange. The nurse understands that these nursing diagnoses would be organized under which functional pattern?

Activity-exercise

When planning initial care for a 16-year-old client and the client's newborn, the nurse formulates a nursing diagnosis of "Risk for Impaired Attachment." What would be the nurse's most appropriate action to take next?

Assess the client's interactions with the newborn.

Which is true of nursing diagnoses?

Describe the client's response to the health problem

Which information ensures accuracy when the nurse is developing a nursing diagnosis?

A cluster of clinical cues

Which nursing diagnosis has the priority when caring for an older adult client with Alzheimer disease?

Risk for Injury

A nursing diagnosis of "Complicated Grieving" has been identified for a client whose spouse died 1 year ago. What assessment data would be appropriate evidence to justify this diagnosis? Select all that apply.

The client no longer indulges in usual activities.

The client attempted suicide 1 month ago.

The client states, "I have no interest in doing anything."

A nurse has selected a nursing diagnosis and is preparing to validate it. With whom would the nurse do this?

Client

The nurse formulates the following nursing diagnosis: Disturbed Body Image related to decreased ability to cope with surgical removal of right breast as evidenced by the client refusing to look at the surgical site and stating, "I'm ugly. My husband will no longer find me desirable." What is the etiology identified in this nursing diagnosis?

Decreased ability to cope with surgical removal of right breast

Explanation:

Which statement appropriately identifies a risk nursing diagnosis for a client who is confined to bed?

Risk for Impaired Skin Integrity related to bed rest

The client is admitted to the surgical unit following an exploratory laparotomy. Which nursing diagnosis is the priority?

Impaired skin integrity

The nurse has been assigned to a group of clients. Which client should be the nurse's priority?

A 32-year-old client with a urinary tract infection who is receiving an intravenous antibiotic and reporting swelling in the tongue.

A nurse sees the client grimace and documents that the client is in pain, without interviewing the client to obtain further cues. The nurse has:

a lack of cues, or premature closure.

A client with congestive heart failure has dyspnea while ambulating to the bathroom. The nurse selects the nursing diagnosis of "Activity Intolerance" to address this health problem. Which etiology would be appropriate to select for this nursing diagnosis?

Compromised oxygen transport

A nurse is caring for a client admitted with dehydration after completing a triathlon in a hot, dry climate. The nurse identifies an appropriate nursing diagnosis for this client as "Deficient Fluid Volume related to insufficient fluid intake as evidenced by blood pressure of 84/46 mm Hg, heart rate of 145 beats/min, concentrated urine, and client reporting drinking 200 mL of water during the 4-hour event." Which is the problem statement in this nursing diagnosis?

Deficient fluid volume

Which error has the nurse made in formulating the following nursing diagnosis: Prolonged Immobility related to impaired skin integrity as evidenced by an open area with a 1-inch diameter on the right buttocks surrounded by a 1-inch margin of redness; wound surface clean and beefy red; no drainage or foul odor detected.

Reversed the health problem and the etiology

The nurse is admitting a client who is unable to identify person, place, or time. To properly analyze these data, what action must the nurse take?

Interview the client's family to assess the client's usual level of cognition.

What is the purpose of establishing a nursing diagnosis?

To describe a functional health problem

Which assessment findings would support the nursing diagnosis of Acute Pain? Select all that apply.

The client had an abdominal hysterectomy 1 day ago.

The client is crying in pain about 20 minutes before pain medicine is due.

Which is an example of a nursing diagnosis?

Constipation

Which assessment findings would support the nursing diagnosis of Impaired Skin Integrity? Select all that apply.

Impaired mobility due to recent stroke

Unable to turn in bed without assistance

Uncontrolled diabetes

A 19-year-old college basketball player is being evaluated for injuries after a skiing accident. The nurse determines that the client has a pulse of 52 beats/min. What would be the most appropriate way for the nurse to determine the significance of the client's heart rate?

Ask the client whether the heart rate is normal for the client.

A client is brought to the emergency room in respiratory arrest and is immediately intubated and placed on mechanical ventilation. What is the most appropriate nursing diagnosis for this client?

Ineffective spontaneous ventilation

One major requirement of a nursing diagnosis is that it focus on a problem that is:

legally treatable by registered nurses.

The care plan for a postoperative client includes a nursing diagnosis of "Risk for Urinary Retention." The nurse determines that the client has been voiding adequately. What is the nurse's most appropriate action?

Revise the nursing diagnosis because the client's status has changed.

The nurse is assessing a client who was just admitted to the unit following an abdominal hysterectomy. On which assessment finding would the nurse base the priority diagnosis?

Diminished breath sounds in left lower lobe

The nurse is caring for a client who has been diagnosed with a sexually transmitted infection (STI) for the fourth time in 4 years. The nurse plans to address the potential concern for the client's risk-prone behavior. What assumption prompted the nurse to address this concern?

Having multiple STIs over multiple years means the client is sexually active.

A nurse is caring for a marathon runner who collapsed while running in extremely warm weather. Upon admission, the client's temperature is 102°F (38.9°C). What is the most appropriate nursing diagnosis?

Hyperthermia

While caring for a client recovering from a cerebrovascular accident, the nurse determines that the client would benefit from the services of physical therapy. How should the nurse plan to involve physical therapy in the client's care?

By formulating a collaborative problem

A client who is scheduled for coronary angioplasty is concerned about whether the surgery is safe and wonders whether it would be beneficial. Which nursing diagnosis relates to this client's condition?

Fear related to potential risk and surgical outcomes

An older adult client recently admitted to a long-term care facility expresses anger and depression about the relocation. The client consumes very little food and is losing weight. Which nursing diagnosis would be most appropriate for the nurse to select to plan this client's care?

Relocation Stress Syndrome

Which error has the nurse made in formulating the nursing diagnosis: Pain related to nurse failing to administer pain med in a timely manner as evidenced by client pain rating of 7 out of 10, client guarding abdominal incision, client ambulating slowly?

Used legally inadvisable terms

Which guidelines should the nurse consider when writing outcomes? Select all that apply.

The nurse should not be concerned if the client and family do not value the outcomes as long as they support the plan of care.

The nurse should write outcomes that are brief and specific and support the overall plan of care.

The nurse may write outcomes that do not specify a timeline as long as they are linked with other outcomes.

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology:

identifies factors causing undesirable response and preventing desired change.

Which guideline should the nurse follow when including interventions in a plan of care?

Date the nursing interventions when written and when the plan of care is reviewed.

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?

A standardized care plan

A nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, three times per day, leads to expedited discharge. What type of evaluation best describes what the researchers are examining?

Outcome

A nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair next to the client's bed and holds the client's hand while listening to the client's story. What type of nursing intervention is the nurse engaging in?

Supportive

Which is an example of a nurse-initiated intervention?

Teach the client how to splint an abdominal incision when coughing and deep breathing

The expected outcome for a client with a new diagnosis of diabetes mellitus is: "Client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met?

"I will test my glucose level before meals and use sliding scale insulin."

A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care?

Seek research about the disorder.

A nurse is writing outcomes for a client who is scheduled to ambulate following hip replacement surgery. Which is a correctly written outcome for this client?

Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.

The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, "I have smoked since I was 12 years old. I am not going to stop now." What is the appropriate response by the nurse?

"Please tell me your thoughts about treating this diagnosis."

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?

Client will have formed stools within 24 hours.

One of the primary factors that the nurse considers when setting priorities for the client in the acute care setting after cardiac surgery is the client's:

condition.

A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based on improvements in the client's condition. This is an example of which type of planning?

Ongoing

A nurse is caring for a client who began taking the antidepressant paroxetine 2 weeks ago. The client recently began giving away prized possessions and tells the nurse, "My mind is made up, I can't do this any longer." What is the best action by the nurse to incorporate this information into the plan of care?

Add the nursing diagnosis: Risk for Self-Harm.

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:

discharge planning.

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do?

Individualize the plan to the client.

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?

Psychomotor

After the health history and admission assessment are completed, the nurse establishes a care plan for the client. What is the rationale for documenting and planning the client's care?

It helps deliver holistic, goal-oriented, individualized care.

What is true of nursing responsibilities with regard to a health care provider-initiated intervention (health care provider's order)?

Nurses do carry out interventions in response to a health care provider's order.