Fundamentals Nursing Active Learning 1st

Edition Yoost Crawford – Test Bank

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Fundamentals Nursing Active Learning 1st Edition Yoost Crawford – Test Bank

Chapter 06: Assessment

MULTIPLE CHOICE

1. The nurse is caring for a patient with pneumonia. The patient is a retired soldier who served in
World War II. In light of this, the nurse should:

a. shake the patient’s hand and allow the patient time to “warm up.”

b. expect the patient to be optimistic and question everything.

c. allow the patient to multitask and talk in short “sound bites.”

d. understand that the patient is probably technologically literate.

ANS: A

Establishing rapport is paramount to gaining the trust of the patient. The nurse should consider
the patient’s generational cohort, which may influence behavior, and willingness to share
personal information during the interview process. Veterans (born before 1945) respect
authority; are detail oriented; communicate in a discrete, formal, respectful way; may be slow to
warm up; value family and community; and accept physical touch as an effective form of
therapeutic communication. Baby Boomers (born 1946-1964) are optimistic, relationship
oriented, and communicate by using open or direct speech, using body language, and answering
questions thoroughly. They expect detailed information, question everything, and value success.
Generation X members (born 1965-1976) are informal; are technology immigrants; multitask;
communicate in a blunt or direct, factual, and informal style; may talk in short sound bites; share
information frequently; and value time. Millennials (born 1977-1997) are flexible; are
technologically literate or are technology natives; multitask; communicate by using action verbs
and humor; may be brief in the form of texting or e-mail exchanges; like personal attention; and
value individuality.

DIF: Applying REF: p. 85 OBJ: 6.1 TOP: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care

NOT: Concepts: Communication

2. The patient interview consists of three phases: orientation (introductory), working, and
termination. Each phase contributes to the development of trust and engagement between the
nurse and the patient. During the orientation phase of the interview, the nurse should:

a. obtain demographic data using open-ended questions.

b. establish the name by which the patient prefers to be addressed.

c. gather general information using closed-ended questions.

d. stand by the bedside to ask the needed questions.

ANS: B
The patient interview consists of three phases: orientation (introductory), working, and
termination. Each phase contributes to the development of trust and engagement between the
nurse and the patient. During the orientation phase of the interview, the nurse should establish
the name by which the patient prefers to be addressed. Some individuals prefer formal titles of
respect (e.g., Dr., Mr., Ms., Professor) and the use of surnames, whereas others are comfortable
with less formality. How a patient is addressed is the patient’s choice. Demographic data should
be collected by asking focused or closed-ended questions. More general information can be
gathered by open-ended communication techniques. When feasible, the nurse and the patient
should be seated at eye level with each other. In this way, the interaction between the nurse and
the patient is horizontal instead of vertical. Standing over someone implies control, power, and
authority. The implication of power can result in less-than-optimal data collection and a potential
conflict as the patient strives to regain control over the situation.

DIF: Applying REF: pp. 84-85 OBJ: 6.1 TOP: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care

NOT: Concepts: Communication

3. A nurse is conducting a health interview on a newly admitted patient. To establish a trusting

relationship with the patient, the nurse:

a. avoids eye contact to appear less threatening.

b. demonstrates professionalism by not smiling.

c. sits close and leans in slightly toward the patient.

d. speaks in a slow rate of speech and low tone.

ANS: C

Nonverbal behaviors of the nurse can influence the information obtained from the patient.
Negative nonverbal cues such as distracting gestures (e.g., tapping a pen, swinging a foot,
looking at a watch), inappropriate facial expressions, and lack of eye contact communicate
disinterest. To establish a trusting relationship with the patient before the physical examination is
conducted, the nurse should communicate professionally, sit close and lean in slightly toward the
patient, listen attentively and demonstrate appropriate eye contact, smile, and use a moderate rate
of speech and tone of voice.

DIF: Applying REF: p. 85 OBJ: 6.1 TOP: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care

NOT: Concepts: Communication

4. The nurse is assigned the admission health history and physical for a patient diagnosed with a
fever of unknown etiology. The patient tells the nurse, “I just don’t feel good. I’m so hot and I
feel sick to my stomach. Can you ask me those questions later?” The best response by the nurse
is:

a. “It will not take too long. I can hurry.”

b. “We need the information to complete your admission paperwork.”

c. “I will come back in a few minutes and we can start over.”

d. “Let me see if you can have something for the nausea and then talk later.”

ANS: D

If a patient being admitted to the hospital is too ill to interact for an extended period, the
interview can be broken into smaller segments. Interviews with patients already hospitalized or
established in the health care system are less extensive and more focused on newly identified
patient concerns or problems. Ensuring that the patient is comfortable and relaxed is a priority
and often takes prior thought and planning by the nurse.

DIF: Applying REF: pp. 85-86 OBJ: 6.1 TOP: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care
NOT: Concepts: Communication

5. The nurse is using a stethoscope to assess a patient’s cardiac status. This assessment technique
is known as:

a. inspection.

b. percussion.

c. palpation.

d. auscultation.

ANS: D

Auscultation is a technique of listening with the assistance of a stethoscope to sounds made by

organs or systems such as the heart, blood vessels, lungs, and abdominal cavity. Inspection
involves the use of vision, hearing, and smell to closely scrutinize physical characteristics of a
whole person and individual body systems. Percussion involves tapping the patient’s skin with
short, sharp strokes that cause a vibration to travel through the skin and to the upper layers of the
underlying structures. Vibration is reflected by the tissues, and the character of the sound heard
depends on the density of the structures that reflect the sound. Palpation uses touch to assess
body organs and skin texture, temperature, moisture, turgor, tenderness, and thickness.

DIF: Remembering REF: p. 88 OBJ: 6.2

TOP: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

NOT: Concepts: Caregiving

6. The nurse is performing an assessment of a patient’s right kidney. The nurse bluntly strikes the
area of the costovertebral angle while observing the patient’s reaction. The physical assessment
technique being used is:
a. inspection.

b. percussion.

c. palpation.

d. auscultation.

ANS: B

Percussion involves tapping the patient’s skin with short, sharp strokes that cause a vibration to
travel through the skin and to the upper layers of the underlying structures. Inspection involves
the use of vision, hearing, and smell to closely scrutinize physical characteristics of a whole
person and individual body systems. Palpation uses touch to assess body organs and skin texture,
temperature, moisture, turgor, tenderness, and thickness. Auscultation is a technique of listening
with the assistance of a stethoscope to sounds made by organs or systems such as the heart, blood
vessels, lungs, and abdominal cavity. Vibration is reflected by the tissues, and the character of
the sound heard depends on the density of the structures that reflect the sound.

DIF: Remembering REF: p. 88 OBJ: 6.2

TOP: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

NOT: Concepts: Caregiving

7. The nurse is performing a physical exam on a patient diagnosed with liver failure resulting from
chronic alcoholism. The nurse notes that the abdomen is swollen and decides to assess for
abdominal skin tenderness and temperature. Which of the following techniques would the
nurse use to collect this data?

a. Inspection

b. Percussion

c. Palpation
d. Auscultation

ANS: C

Palpation uses touch to assess body organs and skin texture, temperature, moisture, turgor,
tenderness, and thickness. Inspection involves the use of vision, hearing, and smell to closely
scrutinize physical characteristics of a whole person and individual body systems. Percussion
involves tapping the patient’s skin with short, sharp strokes that cause a vibration to travel
through the skin and to the upper layers of the underlying structures. Auscultation is a technique
of listening with the assistance of a stethoscope to sounds made by organs or systems such as the
heart, blood vessels, lungs, and abdominal cavity. Vibration is reflected by the tissues, and the
character of the sound heard depends on the density of the structures that reflect the sound.

DIF: Remembering REF: p. 88 OBJ: 6.2

TOP: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

NOT: Concepts: Caregiving

8. The triage nurse in a hospital emergency department is determining the order of care for several
patients. Which of the following would the nurse consider as having the highest priority?

a. A 68-year-old patient suffering from dehydration and disorientation

b. A 14-year-old patient having respiratory distress and increasing anxiety

c. A 46-year-old patient with multiple cuts and abrasions to the upper extremities

d. A 38-year-old patient with a broken right hip and in severe pain

ANS: B
Triage, a form of emergency assessment, is the classification of patients according to treatment
priority. Patients are categorized by the urgency of their condition. Most emergency departments
use a three- or five-tier triage system; the trend is toward a five-tier system. The classifications in
the three-tier system are emergent, urgent, and non-urgent. The five-tier system classifies
patients by levels numbered 1 through 5. Level 1 is considered critical: life-threatening
conditions require immediate and continuous care such as severe trauma, cardiac arrest,
respiratory distress, seizure, or shock. Level 2 emergencies can be imminently life-threatening
conditions requiring care within 30 minutes, such as chest pain or major fractures, with severe
pain. Level 3 is considered urgent: potentially life-threatening conditions that require care within
30-60 minutes, such as minor fractures, lacerations, and dehydration. Level 4 is considered non-
urgent, stable health conditions that require care within 60-120 minutes, such as sore throats and
abrasions.

DIF: Analyzing REF: pp. 89-90 OBJ: 6.3 TOP: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

NOT: Concepts: Caregiving

9. The morning nurse is assigned to care for a patient admitted during the night with rectal
bleeding. When making rounds, the nurse observes that the patient’s face is ashen in color and
the skin is cool and clammy. The nurse auscultates the patient’s heart and lungs. Which category
of physical assessment is the basis for the nurse’s response?

a. Emergency

b. Focused

c. Complete

d. Initial comprehensive

ANS: A

Emergency assessment is a physical examination done when time is a factor, treatment must
begin immediately, or priorities for care need to be established in a few seconds or minutes.
Attention is paid to the patient’s airway, breathing, and circulation. Other concerns in the
emergent setting are noticeable deformities such as compound fractures, contusions, abrasions,
puncture wounds, burns, tenderness, lacerations, bleeding, and swelling. During an emergency,
the nurse may never have time to do a complete assessment and may work to stabilize one body
system at a time. A focused or clinical assessment is a brief individualized physical examination
conducted at the beginning of an acute care–setting work shift to establish current patient status
or during ongoing patient encounters in response to a specific patient concern. A focused
assessment may be conducted when signs indicate a change in a patient’s condition or the
development of a new complication. A comprehensive or complete assessment includes a
thorough interview, health history, review of systems, and extensive physical head-to-toe
assessment, including evaluation of cranial nerves and sensory organs, such as with sight and
hearing testing. A complete physical examination may be conducted on admission to a hospital,
during an annual physical at the office of a physician or nurse practitioner, or on initial
interaction with a specialist.

DIF: Remembering REF: p. 89 OBJ: 6.3

TOP: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

NOT: Concepts: Caregiving

10. The nurse is performing her initial assessment of the day when she notices that the patient has a
facial droop that he did not have yesterday and that was not reported in the hand-off report
from the night nurse. The nurse proceeds to assess the neurological status of the patient. This
type of assessment is known as:

a. an emergency assessment.

b. a focused assessment.

c. a complete physical examination.

d. a comprehensive assessment.

ANS: B

A focused or clinical assessment is a brief individualized physical examination conducted at the

beginning of an acute care–setting work shift to establish current patient status or during ongoing
patient encounters in response to a specific patient concern. A focused assessment may be
conducted when signs indicate a change in a patient’s condition or the development of a new
complication. Emergency assessment is a physical examination done when time is a factor,
treatment must begin immediately, or priorities for care need to be established in a few seconds
or minutes. Attention is paid to the patient’s airway, breathing, and circulation. Other concerns in
the emergent setting are noticeable deformities such as compound fractures, contusions,
abrasions, puncture wounds, burns, tenderness, lacerations, bleeding, and swelling. A
comprehensive or complete assessment includes a thorough interview, health history, review of
systems, and extensive physical head-to-toe assessment, including evaluation of cranial nerves
and sensory organs, such as with sight and hearing testing. A complete physical examination
may be conducted on admission to a hospital, during an annual physical at the office of a
physician or nurse practitioner, or on initial interaction with a specialist.

DIF: Remembering REF: p. 89 OBJ: 6.3

TOP: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

NOT: Concepts: Caregiving

11. The nurse is documenting data collected during a health assessment interview. Which
statement indicates subjective data?

a. “My last bowel movement was 4 days ago.”

b. Abdomen distended; firm and tender.

c. Dark colored; hard pellet-shaped stool.

d. Color pink. Skin warm and dry. No sign of discomfort.

ANS: A

Subjective data are spoken information or symptoms that cannot be authenticated. Subjective
data usually are gathered during the interview process if patients are well enough to describe
their symptoms. Objective data, also referred to as signs, can be measured or observed. The
nurse’s senses of sight, hearing, touch, and smell are used to collect objective data. Objective
assessment data are acquired through observation, physical examination, and analysis of
laboratory and diagnostic test results.

DIF: Analyzing REF: pp. 90-91 OBJ: 6.4 TOP: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

NOT: Concepts: Caregiving

12. A patient is transported to the emergency room from a local skilled nursing facility and admitted
for a bacterial blood infection. The nurse reviews the transferring physician notes, which
indicate that the patient has dementia. The nurse contacts the patient’s son for additional
health history information. Information provided by the son would be considered:

a. primary, objective data.

b. primary, subjective data .

c. secondary, objective data.

d. secondary, subjective data.

ANS: D

Subjective data are spoken information or symptoms that cannot be authenticated. Subjective
data usually are gathered during the interview process if patients are well enough to describe
their symptoms. Family members, friends, and other members of the health care team can
contribute valid secondary, subjective data. Objective data, also referred to as signs, can be
measured or observed. The nurse’s senses of sight, hearing, touch, and smell are used to collect
objective data. Objective assessment data are acquired through observation, physical
examination, and analysis of laboratory and diagnostic test results. Primary data come directly
from the patient.

DIF: Remembering REF: pp. 90-91 OBJ: 6.4

TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

NOT: Concepts: Caregiving

13. The nurse is monitoring the blood sugar results of a patient receiving an intravenous nutritional
supplement. The patient tells the nurse, “I have never had sugar problems before. My doctor
says it is because I am getting this sugar water.” These types of data are considered:

a. primary, objective data.

b. primary, subjective data.

c. secondary, objective data.

d. secondary, subjective data.

ANS: B

Primary data come directly from the patient. Subjective data are spoken information or
symptoms that cannot be authenticated. Subjective data usually are gathered during the interview
process if patients are well enough to describe their symptoms. Family members, friends, and
other members of the health care team can contribute valid secondary, subjective data. Objective
data, also referred to as signs, can be measured or observed. The nurse’s senses of sight, hearing,
touch, and smell are used to collect objective data. Objective assessment data are acquired
through observation, physical examination, and analysis of laboratory and diagnostic test results.

DIF: Remembering REF: pp. 90-91 OBJ: 6.4

TOP: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

NOT: Concepts: Caregiving

14. The unlicensed nursing assistive person (UAP) reports to the nurse that a patient is crying during
a comedy show on television. The nurse’s best response should be:
a. “Maybe the patient doesn’t think the show is funny.”

b. “Don’t worry about it. Her daughter says this is normal.”

c. “I will go visit her right away and see what is going on.”

d. “Just document what you observe in your notes.”

ANS: C

Validating data is making sure that the data are accurate. As patient information is collected,
consistency between subjective and objective data must be confirmed. Confirming the validity of
collected data often requires verbally checking with the patient to see whether assumptions or
conclusions at which the nurse arrived are correct. Crying, a disheveled appearance, and lack of
eye contact may be cues of depression. However, conclusions about the underlying cause of the
patient’s actions cannot be assumed. All cues need to be interpreted and validated to verify the
data’s accuracy. The nurse cannot assume that this is normal behavior nor ignore the problem by
making a joke. The nurse has the responsibility to attempt to determine the real reason for the
crying episode.

DIF: Applying REF: p. 91 OBJ: 6.5 TOP: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

NOT: Concepts: Caregiving

15. A patient with moderate lower back pain tells the nurse, “My urine smells awful and is as dark as
my glass of tea.” Which action will assist in validating the patient’s concern?

a. Ask the patient to describe the back pain.

b. Review the lab results of the most recent urinalysis.

c. Request the nursing assistant to obtain a set of vital signs.

d. Check the patient’s history for urinary tract infections.

ANS: B

As patient information is collected, consistency between subjective and objective data must be
confirmed. Sometimes, the nurse can use laboratory and diagnostic test results to validate the
subjective data. For example, objective data can validate patient subjective data when the
patient’s hemoglobin level is low, indicating anemia, and the patient complains of feeling
fatigued and dizzy. The nurse has the responsibility to attempt to determine the reason behind the
patient’s complaint. Obtaining a set of vital signs, reviewing the patient’s history, and exploring
the patient’s pain are appropriate actions but cannot validate the current problem.

DIF: Applying REF: p. 91 OBJ: 6.5 TOP: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

NOT: Concepts: Caregiving

16. The nurse is attempting to get the patient to sign the operative consent. When asked if the
health care provider explained the procedure to the patient, the patient replies “Not much.” The
nurse should:

a. develop a comprehensive teaching plan related to the surgical procedure.

b. ask the patient what information the doctor has explained about the surgery.

c. contact the surgeon and ask for further clarification of information given to patient.

d. focus on postoperative exercises and home-care following surgery.

ANS: B

Careful observation and attention to detail help the nurse to notice subtle cues and recognize how
best to validate and interpret patient data. The nurse must be careful not to make false
assumptions or generalizations regarding the patient’s responses to the health concern. The nurse
is correct to ask the patient about the upcoming surgical procedure instead of assuming that the
patient has limited knowledge. Developing a comprehensive teaching plan is not necessary until
further clarification is obtained. Focusing on postoperative treatment plans is important but not
the priority at this time. It is not appropriate to contact the surgeon unless the patient
demonstrates an actual knowledge deficit.

DIF: Applying REF: p. 91 OBJ: 6.5 TOP: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

NOT: Concepts: Caregiving

17. After the patient’s data are collected, validated, and interpreted, the nurse organizes the
information in a framework (format) that facilitates access by all members of the health care
team. The framework that provides the most holistic view of the patient’s condition is:

a. the head-to-toe pattern

b. Marjory Gordon’s Functional Health Patterns.

c. the cephalic-caudal pattern.

d. the body systems model.

ANS: B

Marjory Gordon (2010) developed functional health patterns to help nurses focus on patient
strengths and related but sometimes overlooked data relationships. For instance, one of the
functional health patterns is activity and exercise. In this health pattern, the patient data related to
cardiac, respiratory, and musculoskeletal function are recorded because the ability of a patient to
initiate and continue activity depends on the condition of the heart, lungs, and muscles and
bones. This method of organizing patient data is a more holistic approach than the others.

Organizing assessment data in a head-to-toe (cephalic-caudal) pattern ensures that all areas of
concern are addressed. The nurse documents information regarding the patient’s general health
status first, including data related to psychosocial concerns, emotional status, cultural and ethnic
influences, and living conditions. Vital sign assessment data are then recorded, followed by
objective and subjective patient information. Physical assessment data are documented, starting
with the head and ending with findings related to the lower extremities. The body systems model
organizes data on the basis of each system of the body: integumentary, respiratory,
cardiovascular, nervous, reproductive, musculoskeletal, gastrointestinal, genitourinary, and
immune systems. It follows a sequence similar to the medical model for physical examination.
The body systems model for data organization tends to focus on the physical aspects of a
patient’s condition rather than a more holistic view.

DIF: Remembering REF: p. 92 OBJ: 6.6

TOP: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

NOT: Concepts: Caregiving

18. The wound care nurse is assessing a non-healing leg wound on a patient recently admitted for
uncontrolled diabetes. The nurse organizes the data using Gordon’s Functional Health Pattern
of:

a. nutrition and metabolism.

b. activity and exercise.

c. sleep and rest.

d. elimination.

ANS: A

Health assessment data is organized in frameworks that provide a comprehensive view of a

patient’s health. Gordon’s Functional Health Pattern focuses on patient’s strengths and
relationships of the data collected. The focus of nutrition and metabolism is tissue integrity. Data
collected during a wound assessment would be classified in this health pattern. Activities of daily
living and musculoskeletal information are the focus of activity and exercise. Sleep and rest
includes sleep patterns, relaxation activities, and levels of fatigue. Bowel and urinary concerns
are the focus of elimination.
DIF: Remembering REF: pp. 92-93 OBJ: 6.6

TOP: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

NOT: Concepts: Caregiving

19. During the health history interview, the patient tells the nurse, “Just walking to the mailbox and
back makes my calves ache. Is this normal?” Which of the following frameworks would the
nurse most likely choose to document this data?

a. Head-to-toe model

b. Gordon’s Functional Health Patterns

c. Body systems model

d. Cephalic-caudal model

ANS: C

The body systems model organizes data on the basis of each system of the body: integumentary,
respiratory, cardiovascular, nervous, reproductive, musculoskeletal, gastrointestinal,
genitourinary, and immune systems. It follows a sequence similar to the medical model for
physical examination. The body systems model for data organization tends to focus on the
physical aspects of a patient’s condition rather than a more holistic view. Organizing assessment
data in a head-to-toe (cephalic-caudal) pattern ensures that all areas of concern are addressed.
The nurse documents information regarding the patient’s general health status first, including
data related to psychosocial concerns, emotional status, cultural and ethnic influences, and living
conditions. Vital sign assessment data are then recorded, followed by objective and subjective
patient information. Physical assessment data are documented, starting with the head and ending
with findings related to the lower extremities. Marjory Gordon developed functional health
patterns to help nurses focus on patient strengths and related but sometimes overlooked data
relationships. For instance, one of the functional health patterns is activity and exercise. In this
health pattern, the patient data related to cardiac, respiratory, and musculoskeletal function are
recorded because the ability of a patient to initiate and continue activity depends on the condition
of the heart, lungs, and muscles and bones. This method of organizing patient data is a more
holistic approach than the others.
DIF: Remembering REF: p. 92 OBJ: 6.6

TOP: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

NOT: Concepts: Caregiving

MULTIPLE RESPONSE

1. An in-depth health history: (Select all that apply.)

a. includes demographic data.

b. lists the patient’s allergies.

c. contains the family history of diseases.

d. explains the patient’s health promotion practices.

e. is completed only once and can be recalled electronically.

ANS: A, B, C, D

An in-depth health history includes all pertinent information that can guide the development of a
patient-centered plan of care. The health history includes demographic data, which are collected
during the orientation phase of the interview; a patient’s chief complaint or reason for seeking
health care; history of current illness; allergies; medications; adverse reactions to medications;
medical history; family and social history; and health promotion practices. Because a patient’s
health history is continuously evolving, the data collection is ongoing, progressive, and
methodical.

DIF: Remembering REF: p. 86 OBJ: 6.1

TOP: Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care

NOT: Concepts: Communication

2. The nurse is admitting a patient for uncontrolled diabetes mellitus. The nurse suspects that the
patient could benefit from diabetic teaching. To corroborate her suspicion, during the patient
interview the nurse: (Select all that apply.)

a. determines the patient’s cognitive ability and potential language barriers.

b. gathers information about what the patient already knows about diabetes.

c. Attempts to determine the need for referrals and education.

d. Formulates the patient’s plan of care using a standard protocol.

e. Prepares to teach the patient using materials written at a third-grade level.

ANS: A, B, C

Educational needs are assessed during the patient interview. The nurse should document gaps in
patient knowledge and areas in which clarification of disease processes or treatment would be
beneficial. Prior to initiating patient education, the nurse needs to assess a patient’s cognitive
ability, reading level, and potential language barriers. Assessment should include collecting
information about what the patient already knows about her/his current condition and what
additional knowledge is needed. Assessment information about the patient’s educational needs
should be documented and should guide aspects of the patient’s individualized plan of care.
Thorough assessment of the patient’s knowledge should be used to determine the need for
referrals and educational interventions.

DIF: Remembering REF: p. 86 OBJ: 6.1

TOP: Assessment MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT: Concepts: Health Promotion

 3. The nurse is preparing to begin a physical examination for a patient with open lesions on the
lower extremities. Which should the nurse evaluate during the physical assessment? (Select all
that apply.)

a. Blood test results

b. X-ray results

c. Recent vital signs

d. Patient’s health history

e. Subjective data

ANS: A, B, C

On completion of the patient interview, health history, and review of systems, the nurse begins
the physical assessment. During the physical assessment, the nurse collects objective data. If
diagnostic tests, such as blood tests or x-rays, were ordered before the patient was seen, the
results are reviewed by the nurse. Vital signs are taken and recorded at the beginning of the
physical examination.

DIF: Applying REF: p. 88 OBJ: 6.2 TOP: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care

NOT: Concepts: Care Coordination

4. The charge nurse is planning vital sign assignments for the unlicensed assistive personnel (UAP)
on a busy medical–surgical unit. Which patients are appropriate for the UAP to obtain vital
signs? (Select all that apply.)

a. A 28-year old patient scheduled to be discharged home today

b. A 49-year-old patient with stable chronic lung disease

c. A 78-year-old patient with recent onset of rectal bleeding

d. A 35-year-old patient waiting for transfer to a rehabilitation center

e. A 40-year-old patient being admitted from the emergency department

ANS: A, B, D

Routine assessment of vital signs of a patient who is stable may be delegated to Licensed
Practical or Licensed Vocational Nurses (LPNs/LVNs) or qualified UAP. Initial and ongoing
assessment of patients requiring critical care cannot be delegated to UAPs. Initial patient
assessment of unstable patients cannot be delegated to LPNs/LVNs. LPNs/LVNs may contribute
to the ongoing assessment of patients and document their observations and care. The patient with
rectal bleeding needs critical care, and a new admission needs to be assessed by an RN. Stable
patients such as the patient with stable lung disease, or awaiting discharge or transfer can be
delegated to UAP.

DIF: Analyzing REF: p. 89 OBJ: 6.3 TOP: Analysis

MSC: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

NOT: Concepts: Caregiving

5. Which of the following examples given indicate objective data? (Select all that apply.)

a. Respirations – 24 breaths per minute

b. Platelet count – 350,000 mm3

c. Wound size – 3 cm X 2 cm

d. Temperature – 98.4° F (36.8° C)

e. Complaints of severe abdominal pain.

ANS: A, B, C, D

Objective data, also referred to as signs, can be measured or observed. The nurse’s senses of
sight, hearing, touch, and smell are used to collect objective data. Objective assessment data are
acquired through observation, physical examination, and analysis of laboratory and diagnostic
test results. Subjective data are spoken information or symptoms that cannot be authenticated.
Subjective data usually are gathered during the interview process if patients are well enough to
describe their symptoms.

DIF: Remembering REF: pp. 90-91 OBJ: 6.4

TOP: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

NOT: Concepts: Caregiving

6. Patient-centered care requires the nurse to: (Select all that apply.)

a. understand patient preferences

b. be aware of family values

c. recognize the patient’s expectations

d. base conclusions on the nurse’s personal experiences

e. provide care in a standardized manner

ANS: A, B, C

Patient-centered care requires the nurse to understand patient and family preferences and values.
Nurses must recognize patients’ expectations for care and provide care with respect for the
diversity of human experience. While interpreting data, the nurse must be careful to avoid
inaccurate inferences (i.e., conclusions) based on the nurse’s personal preferences, past
experiences, generalizations, or outdated and inaccurate health care information.
DIF: Applying REF: p. 91 OBJ: 6.6 TOP: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

NOT: Concepts: Caregiving

Chapter 07: Nursing Diagnosis

MULTIPLE CHOICE

1. The nurse completes a health and physical assessment on a patient admitted with a fractured
pelvis. Which of the following tasks should the nurse do next?

a. Analyze and cluster the assessment information.

b. Formulate a nursing diagnosis addressing actual issues.

c. Determine the need for potential nursing diagnoses.

d. Create health promotion diagnoses for the patient.

ANS: A

Nursing diagnosis is the second step of the nursing process. Formulation of nursing diagnoses
follows patient data collection and involves the analysis and clustering of related assessment
information. Actual nursing diagnoses identify existing problems or concerns of a patient. Risk
nursing diagnoses apply when there is an increased potential or vulnerability for a patient to
develop a problem or complication. Health-promotion nursing diagnoses are used in situations in
which patients express interest in improving their health status through a positive change in
behavior. The analysis of information is required to determine nursing diagnoses.

DIF: Applying REF: p. 96 OBJ: 7.1 TOP: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care

NOT: Concepts: Care Coordination

2. A group of patients in a community center attend a nursing-led information session on the risks
of contracting tuberculosis. After the presentation several patients ask the nurse for additional
web-based resources regarding the lung disease. Which type of nursing diagnosis would the
nurse choose for the community care plan?

a. Risk

b. Actual

c. Health-promotion

d. Potential

ANS: C

Health-promotion nursing diagnoses are used in situations in which patients express interest in
improving their health status through a positive change in behavior. Although most nursing
diagnoses are used for individual patients, nursing diagnosis taxonomy can be applied to
families, groups of individuals, and communities. Actual nursing diagnoses identify existing
problems or concerns of a patient. Risk (potential) nursing diagnoses apply when there is an
increased potential or vulnerability for a patient to develop a problem or complication.

DIF: Applying REF: p. 96 OBJ: 7.1 TOP: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
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NOT: Concepts: Care Coordination

 3. A nurse completes a care plan for an assigned patient diagnosed with an inflammation of the
pericardium. Which diagnosis written on the plan indicates a need for further instruction on
using the nursing process?

a. Pericarditis

b. Acute pain

c. Risk for decreased cardiac output

d. Activity intolerance

ANS: A

Whereas medical diagnoses identify and label medical (physical and psychological) illnesses,
nursing diagnoses are much broader in focus. Nursing diagnoses consider a patient’s response to
medical diagnoses and life situations in addition to making clinical judgments based on a
patient’s actual medical diagnoses and conditions. Pericarditis is a medical diagnosis defined as
an inflammation of the pericardium. Pain, decreased blood flow, and intolerance to activity are a
patient’s response to the medical condition of pericarditis.

DIF: Analyzing REF: p. 97 OBJ: 7.1 TOP: Evaluation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care

NOT: Concepts: Care Coordination

4. North American Nursing Diagnosis Association International (NANDA-I) is an organization

focusing on revising nursing diagnosis taxonomy and evaluates nursing research to validate the
diagnostic labels. The NANDA-I taxonomy and new nursing diagnoses are published every:

a. 2 years.

b. 3 years.

c. 4 years.
d. 5 years.

ANS: A

The NANDA-I taxonomy is dynamic. Every 2 years, NANDA-I members meet to focus on
revision of the taxonomy and evaluation of nursing research conducted to validate current and
evolving nursing diagnoses.

DIF: Remembering REF: p. 97 OBJ: 7.2

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NOT: Concepts: Care Coordination

5. A patient is receiving an experimental drug for leukemia. The nurse is worried that the drug may
cause a reduction in platelets leading to intestinal tract bleeding. Which type of nursing
diagnosis should the nurse use to address this concern?

a. Risk

b. Actual

c. Health-promotion

d. Medical diagnosis

ANS: A

The three types of nursing diagnostic statements are actual, risk, and health promotion.
Determining which type is needed for each patient can be challenging. Risk (potential) nursing
diagnoses apply when there is an increased potential or vulnerability for a patient to develop a
problem or complication. Actual nursing diagnoses identify existing problems or concerns of a
patient. Health-promotion nursing diagnoses are used in situations in which patients express
interest in improving their health status through a positive change in behavior. Although most
nursing diagnoses are used for individual patients, nursing diagnosis taxonomy can be applied to
families, groups of individuals, and communities. Medical diagnoses identify and label medical
(physical and psychological) illnesses.

DIF: Remembering REF: pp. 96-98 OBJ: 7.3

TOP: Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
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NOT: Concepts: Care Coordination

6. The nurse is writing the care plan for a patient admitted to the hospital for complications
associated with muscular dystrophy. Which nursing diagnoses written on the care plan indicate
a need for further instruction in constructing the diagnostic statement?

a. Constipation related to immobility as manifested by lower extremity weakness.

b. Activity intolerance related to weakness as evidenced by verbal report of fatigue.

c. Feeding self-care deficit related to fatigue as manifested by inability to swallow food.

d. Ineffective airway clearance related to muscle weakness.

ANS: D

Each type of nursing diagnostic statement contains sections or parts. Actual nursing diagnostic
statements are written with three parts: a diagnosis label, related factors, and defining
characteristics. Risk nursing diagnoses have two segments: a diagnosis label and risk factors.
Health-promotion nursing diagnoses are written with only two sections: the diagnosis label and
defining characteristics. The ineffective airway clearance label is missing the defining
characteristics.
DIF: Remembering REF: p. 98 OBJ: 7.4

TOP: Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
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NOT: Concepts: Care Coordination

7. Nursing students are analyzing the following nursing diagnostic statement during a study group
session. Acute pain related to pressure on lumbar spinal nerves as evidenced by a pain level of 9,
patient verbalizations of pain, and grimacing when walking. The students would be correct if
they stated that the etiology of the patient’s problem is:

a. patient verbalizations of pain.

b. acute pain.

c. pressure on lumbar spinal nerves.

d. grimacing when walking.

ANS: C

According to the NANDA-I guidelines, the second part of the nursing diagnosis consists of
related factors (for actual nursing diagnoses) and risk factors (for risk nursing diagnoses).
Related factors are the underlying cause or etiology of a patient’s problem. Risk factors are
environmental, physical, psychological, or situational concerns that increase a patient’s
vulnerability to a potential problem or concern. In this case, the acute pain is being caused by
pressure on the lumbar spinal nerves.

DIF: Remembering REF: p. 99 OBJ: 7.4

TOP: Assessment
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NOT: Concepts: Care Coordination

8. The nurse is caring for a patient diagnosed with blood clots in the right lower extremity. The
admitting physician orders bed rest. The patient tells the nurse, “I usually exercise three times a
week. It helps me go to the bathroom.” The nurse determines that the patient may have
difficulty with bowel movements. Which nursing diagnosis statement accurately reflects the
nurse’s concern?

a. Constipation related to bed rest as manifested by hard, dry stools.

Perceived constipation resulting from patient’s expectation manifested by patient

b.
statement.

c. Risk for constipation related to immobility as manifested by verbal complaint.

d. Risk for constipation related to insufficient physical activity.

ANS: D

Each type of nursing diagnostic statement contains sections or parts. Actual nursing diagnostic
statements are written with three parts: a diagnosis label, related factors, and defining
characteristics. Risk nursing diagnoses have two segments: a diagnosis label and risk factors.
Health-promotion nursing diagnoses are written with only two sections: the diagnosis label and
defining characteristics. There are no data suggesting the patient is constipated at this time.

DIF: Remembering REF: p. 98 OBJ: 7.4

TOP: Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
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NOT: Concepts: Care Coordination

 9. The nursing student is reviewing the components of a nursing diagnosis. Which statement made
by the student indicates correct understanding of a health-promotion diagnostic statement?

a. “The defining characteristics will include the patient’s willingness to get better.”

b. “The risk factors are only psychological in nature, not physical.”

c. “The health-promotion diagnostic statement is composed of three parts.”

d. “An example of a health-promotion label is ineffective community coping.”

ANS: A

The three types of nursing diagnostic statements are actual, risk, and health promotion.
Determining which type is needed for each patient can be challenging. Health-promotion nursing
diagnoses are used in situations in which patients express interest in improving their health status
through a positive change in behavior. The second part of the nursing diagnosis consists of
related factors (for actual nursing diagnoses) and risk factors (for risk nursing diagnoses).
Related factors are the underlying cause or etiology of a patient’s problem. Risk factors are
environmental, physical, psychological, or situational. Health-promotion nursing diagnoses are
written with only two sections: the diagnosis label and defining characteristics. Actual diagnoses
describe the person, family, or community’s response to a health condition or life process that
already has occurred. “Ineffective community coping” would be an example of an actual
problem.

DIF: Understanding REF: pp. 97-99 OBJ: 7.4

TOP: Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
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NOT: Concepts: Care Coordination

10. The nurse is reviewing assessment findings on a patient admitted with an extremely slow heart
rate. The patient complains of dizziness, shortness of breath, chest pain, and fainting spells. Vital
signs are blood pressure of 98/60 mm Hg and pulse of 52 beats/minute. Oxygen saturation is
88%. Which action should the nurse perform next?
a. Exclude all subjective data in favor of objective data.

b. Focus on data gathered during the physical assessment.

c. Evaluate the data looking for patterns and related data.

d. Dismiss family members input as “hearsay.”

ANS: C

After collecting and reviewing all of the assessment data, the nurse looks for patterns and related
data to support specific nursing diagnoses. This process is referred to as clustering data.
Clustering involves organizing patient assessment data into groupings with similar underlying
causes. All patient information should be considered as potentially contributing to the
identification of diagnostic labels. This information includes subjective and objective data
collected through physical assessment of the patient, interview of the patient and family
members, and laboratory and diagnostic test results, including x-rays, physicians’ orders, and
documentation from health care providers. Verifying specific nursing diagnoses for a particular
patient or situation follows accurate analysis and clustering of data.

DIF: Applying REF: pp. 99-100 OBJ: 7.5 TOP: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
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NOT: Concepts: Care Coordination

11. The nurse is admitting a patient with severe dehydration. Assessment data reveal a decreased
blood pressure, an increased pulse rate, and a low circulating blood volume. The student
observes that the patient is confused and restless. Which patient information would the nurse
consider as a contributing factor when choosing the nursing diagnostic label?

a. Blood pressure, pulse rate

b. Blood pressure, pulse rate, blood volume

c. Blood pressure, pulse rate, blood volume, mental status

d. Blood pressure, pulse rate, blood volume, mental status, dehydration

ANS: D

All patient information should be considered as potentially contributing to the identification of

diagnostic labels. This information includes subjective and objective data collected through
physical assessment of the patient, interview of the patient and family members, and laboratory
and diagnostic test results, including x-rays, physicians’ orders, and documentation from health
care providers. Verifying specific nursing diagnoses for a particular patient or situation follows
accurate analysis and clustering of data.

DIF: Applying REF: pp. 99-100 OBJ: 7.5 TOP: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
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NOT: Concepts: Care Coordination

12. The nurse is reviewing data obtained through the health history interview and physical
assessment of an assigned patient. Data collected include dry skin, brittle nails, weight gain,
thinning hair, constipation, prolonged menstruation, and the patient’s complaints of feeling
tired and cold. Which statement represents an appropriate data cluster?

a. Prolonged menstruation, constipation

b. Dry skin, brittle nails, weight gain

c. Tired, cold, thinning hair

d. Constipation, weight gain

ANS: D
Clustering involves organizing patient assessment data into groupings with similar underlying
causes. One patient may have several problems simultaneously, requiring the nurse to understand
the potential relatedness of signs and symptoms from various body systems. The nurse combines
an understanding of pathophysiology, normal structure and function, disease processes, and
symptomatology to accurately cluster data. A person who has not had a bowel movement may
experience weight gain. Skin, nails, and hair are components of the integumentary system. The
subjective feelings of tired and cold are related and prolonged menstruation, as part of the
reproductive system, is in a group by itself.

DIF: Understanding REF: p. 100 OBJ: 7.5

TOP: Planning

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care

NOT: Concepts: Care Coordination

13. The nurse in an outpatient clinic obtains a blood pressure of 190/88 mm Hg on a patient
diagnosed with high blood pressure. The patient tells the nurse, “My blood pressure medicine is
really expensive. Do you think I really need it?” The nurse assumes the patient is not taking the
medication based on the blood pressure result and the patient’s statement and chooses
noncompliance as a diagnostic label. The action by the nurse is an example of:

a. clustering unrelated data in the diagnostic statement.

b. selecting erroneous data for use in the diagnostic statement.

c. using medical diagnoses in the diagnostic statement.

d. identifying multiple problems within one diagnostic statement.

ANS: A

A variety of errors in identification, statement structure, and statement content may occur when
formulating nursing diagnoses. These include clustering unrelated data, accepting erroneous
data, using medical diagnoses as related factors in the nursing diagnostic statement, missing the
true underlying etiology of a problem, and identifying multiple nursing diagnosis labels in one
nursing diagnostic statement. Clustering unrelated data most often occurs when the nurse has not
completed a thorough review of the patient’s assessment information or is missing important
data. The nurse assumes the patient is not taking the blood pressure medication because of the
cost and chooses the diagnosis of noncompliance. The nurse fails to ask the patient if the
medication is being taken as ordered. Errors in data collection (e.g., omitting key information) or
an incomplete understanding or knowledge of assessment techniques or a patient’s condition
may lead to the inclusion of erroneous data in a nursing diagnostic statement. When writing
nursing diagnoses, the nurse should avoid inclusion of more than one label in the statement.
Regardless of the type of nursing diagnosis being written, only one label should be used in each
statement. The nurse does not commit this error here. “Noncompliance” is not a medical
diagnosis.

DIF: Understanding REF: p. 100 OBJ: 7.6

TOP: Planning

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care

NOT: Concepts: Care Coordination

14. The nurse is developing a plan of care for a patient with gastritis and an inflammation of the
intestines. The patient is complaining of severe abdominal discomfort and nausea. The patient
also reports having restless leg syndrome and an inability to urinate. As a problem statement of
the nursing diagnosis, the nurse should write:

a. Gastritis related to inflammation.

b. Alterations in comfort and ability to void.

c. Abdominal pain and nausea related to inflammation.

d. Alteration in comfort related to restless leg syndrome and inflammation.

ANS: C

One patient may have several problems simultaneously, requiring the nurse to understand the
potential relatedness of signs and symptoms from various body systems. The nurse combines an
understanding of pathophysiology, normal structure and function, disease processes, and
symptomatology to accurately cluster data. A variety of errors in identification, statement
structure, and statement content may occur when formulating nursing diagnoses. These include
clustering unrelated data (as with the alteration in comfort and the ability to void), accepting
erroneous data, using medical diagnoses as related factors in the nursing diagnostic statement
(gastritis is a medical diagnosis), missing the true underlying etiology of a problem, and
identifying multiple nursing diagnosis labels in one nursing diagnostic statement. Clustering
unrelated data (such as restless leg syndrome and inflammation) most often occurs when the
nurse has not completed a thorough review of the patient’s assessment information or is missing
important data. Regardless of the type of nursing diagnosis being written, only one label should
be used in each statement. Abdominal pain and nausea, in this case, have the same cause, so
clustering is proper.

DIF: Understanding REF: pp. 100-102 OBJ: 7.6

TOP: Planning

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care

NOT: Concepts: Care Coordination

15. The nursing student submits a care plan to the nursing instructor for a review prior to
implementing the nursing interventions. Which of the following nursing diagnostic statements is
written incorrectly?

Ineffective coping related to inadequate support systems as evidenced by patient’s

a. verbalization, “I don’t have any friends or family in town. I just moved here a week ago.”

Activity intolerance related to immobility as manifested by shortness of breath and

b.
patient’s verbalization of fatigue.

Insomnia and knowledge deficit related to stress as evidenced by patient report of

c.
difficulty sleeping and lack of energy.

Self-care deficit bathing related to upper extremity weakness as manifested by inability to

d.
wash body.
ANS: C

Nurses must be careful when formulating nursing diagnoses. A variety of errors may occur
related to clustering of unrelated data, selecting erroneous data, using medical diagnoses in the
nursing diagnosis statement, and identifying multiple problems within one diagnostic statement.
The student includes two separate nursing diagnostic labels in one statement.

DIF: Understanding REF: p. 100 OBJ: 7.6

TOP: Planning

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
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NOT: Concepts: Care Coordination

16. When creating a nursing diagnosis, the related factor:

a. should be based on the medical diagnosis.

b. in unrelated to the pathophysiology with which the patient is dealing.

c. is the underlying etiology of the patient’s situation.

d. does not reflect the nurse’s understanding of pathophysiology.

ANS: C

The underlying etiology, or cause of a patient’s concern or situation, rather than a medical
diagnosis, should be used as a related factor when writing a nursing diagnosis. By doing so, the
nurse articulates an understanding of the pathophysiology or situation with which the patient is
faced.

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NOT: Concepts: Care Coordination

17. The nurse is caring for a complex patient needing physical and emotional support. As the
primary care giver, the nurse:

a. is ultimately responsible for assessment of patient needs and progress.

b. delegates to people who know what they are doing and operate independently.

c. provides total care to the patient after getting direction from other disciplines.

d. understands that the patient is ultimately responsible for failure or success.

ANS: A

Even though collaboration and delegation may occur, the nurse is ultimately responsible for the
continued assessment of patient needs and progress. As delegator, the nurse must supervise other
disciplines to make sure that the patient needs are being met. Detection of additional problems or
lack of progress with the patient should prompt the nurse to reconsider the nursing process steps.

DIF: Understanding REF: p. 96 | p. 99 OBJ: 7.7

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MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
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NOT: Concepts: Care Coordination

18. The nurse has identified several problems for a patient scheduled for a bone marrow transplant.
By formulation of nursing diagnoses, the nurse:
a. embraces “cook book medicine” and rejects professional autonomy.

b. uses a language that is difficult to interpret by legislators.

c. is able to communicate with other nurses but not other disciplines.

d. facilitates communication of patient needs and promotes accountability.

ANS: D

Nursing diagnosis is the second step of the nursing process. Formulation of nursing diagnoses
follows patient data collection and involves the analysis and clustering of related assessment
information. The use of nursing diagnosis labels facilitates clear communication of patient needs
and promotes professional accountability and autonomy by defining and describing the
independent area of nursing practice. Nursing diagnostic statements clearly communicate to
legislators, consumers, and insurance providers the unique care nurses deliver and the specific
nature of the health conditions they treat. Use of a unified language classification system, or
taxonomy, is an effective vehicle for communication among nurses and other health care
professionals.

DIF: Understanding REF: p. 96 OBJ: 7.7

TOP: Planning

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care

NOT: Concepts: Care Coordination

19. The nurse is developing a plan of care for a patient who has had a stroke. Assessment findings
include weakness in right upper and lower extremities, numbness in face, slurred speech, and
headache. Which of the following would best represent the etiology of the patient’s gait and
balance problems?

a. Lack of muscle motor movement

b. Decreased sensation to touch

c. Inability to speak clearly

d. Pain in back of head

ANS: A

The related factor in an actual nursing diagnosis needs to address the underlying etiology of the
patient’s problem expressed by the nursing diagnostic label rather than listing data that are
defining characteristics. The decreased sensation to touch, inability to speak clearly, and pain in
the back of the head are only reiterations of the defining characteristics (numbness in face,
slurred speech, and headache).

DIF: Understanding REF: p. 101 OBJ: 7.4

TOP: Planning

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care

NOT: Concepts: Care Coordination

20. The nurse is caring for a Vietnamese-American admitted to the intensive care unit as a result of
malnutrition. The patient is unable to walk because of his malnutrition, and he has developed a
pressure ulcer from lying in bed constantly without changing positions. The family believes that
the patient is depressed and that is why he stopped getting up. When planning this patient’s
care, the nurse should:

a. develop multiple nursing diagnoses.

b. develop only one nursing diagnosis to aid in focusing.

c. focus on the physical issues facing this patient.

d. deal primarily with the patient’s psychological needs.

ANS: A

Analysis of patient assessment data may yield several clusters of related data or cues. It is
common to apply several nursing diagnostic statements to one patient. This is especially true for
acutely ill patients with multiple problems related to complex physical or psychological needs.

DIF: Applying REF: p. 100 OBJ: 7.7 TOP: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care

NOT: Concepts: Care Coordination

MULTIPLE RESPONSE

1. The nurse is creating a care plan for a patient admitted with severe bone pain related to an
infected leg wound. Which diagnosis written on the plan indicates an understanding of the
components of a nursing diagnosis? (Select all that apply.)

a. Acute pain

b. Risk for impaired walking

c. Ineffective bone tissue perfusion

d. Osteomyelitis

e. Infection

ANS: A, B, C

Whereas medical diagnoses identify and label medical (physical and psychological) illnesses,
nursing diagnoses are much broader in focus. Nursing diagnoses consider a patient’s response to
medical diagnoses and life situations in addition to making clinical judgments based on a
patient’s actual medical diagnoses and conditions. Pain, potential inability to ambulate, and
decreased blood flow to the bone are a patient’s response to the medical condition of
osteomyelitis. Medical diagnoses identify the specific physical or psychological condition.
Osteomyelitis and infection are medical diagnoses defined as inflammation and an infection of
the bone usually caused by bacteria.

DIF: Analyzing REF: p. 97 OBJ: 7.1 TOP: Evaluation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
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NOT: Concepts: Care Coordination

2. The nurse is caring for a patient admitted to the psychiatric unit as a result of an overdose of
cocaine. Which nursing diagnosis indicates an understanding of a nursing diagnostic statement?
(Select all that apply.)

a. Ineffective breathing pattern related to drug effect on the respiratory center

b. Risk for injury related to hallucinations

c. Insomnia

Chronic confusion related to excessive stimulation of nervous system as evidenced by

d.
impaired socialization

e. Personality conflict

ANS: B, D

Each type of nursing diagnostic statement contains sections or parts. Actual nursing diagnostic
statements are written with three parts: a diagnosis label, related factors, and defining
characteristics. Risk nursing diagnoses have two segments: a diagnosis label and risk factors.
Health-promotion nursing diagnoses are written with only two sections: the diagnosis label and
defining characteristics.
DIF: Remembering REF: p. 98 OBJ: 7.4

TOP: Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care

NOT: Concepts: Care Coordination

3. A patient is admitted to the emergency room after experiencing severe chest pain and difficulty
in taking deep breaths. The patient anxiously tells the nurse, “My father died suddenly of a heart
attack at the age of 52. I’m so scared.” Which nursing diagnoses are appropriate for this
situation? (Select all that apply.)

a. Acute pain

b. Fear

c. Risk for aspiration

d. Risk for infection

ANS: A, B

One patient may have several problems simultaneously, requiring the nurse to understand the
potential relatedness of signs and symptoms from various body systems. The nurse combines an
understanding of pathophysiology, normal structure and function, disease processes, and
symptomatology to accurately cluster data. The patient is reporting severe chest pain with an
inability to take deep breaths. The nursing diagnostic label of acute pain is appropriate. Being
scared is a defining characteristic of the nursing diagnosis of fear. The patient is not at risk for
aspiration or infection based on the data presented.

DIF: Understanding REF: p. 100 OBJ: 7.5

TOP: Planning

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Care
NOT: Concepts: Care Coordination

4. A group of nursing students is discussing the importance of accurately selecting nursing

diagnoses. Which of the following are reasons for choosing the diagnoses carefully? (Select all
that apply.)

a. Patient satisfaction

b. Positive patient outcomes

c. Quality patient care

d. Help develop standardized care plans

e. Determine appropriate interventions

ANS: A, B, C, E

Ultimately, nurses are accountable for formulating accurate nursing diagnoses and intervening
appropriately. By collecting accurate and complete assessment data and articulating concise
nursing diagnoses for each patient, the professional nurse has a significant impact on patient care
outcomes, the quality of patient care, and patient satisfaction. By identifying and writing clear
nursing diagnostic statements, the nurse enables accurate development of individualized patient
plans of care. Nursing diagnoses and patient outcomes, which are established during the planning
step, help the nurse to determine appropriate interventions for patient care.

DIF: Understanding REF: p. 102 OBJ: 7.7

TOP: Planning

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NOT: Concepts: Care Coordination

 5. The nurse has requested an order to place a patient on suicide watch. Which data noted in the
health assessment led the nurse to this conclusion? (Select all that apply.)

a. Threats of killing oneself

b. Chronic pain

c. History of prior suicide attempt

d. Loneliness

e. Stable heart rhythm

ANS: A, B, C, D

Risk factors may be environmental, physical, psychological, or situational concerns. The nurse is
concerned that the patient may be at risk for suicide. Verbal statements by the patient, physical
illness such as chronic pain, prior attempts to commit suicide, and a lack of social interaction are
potential causes for the act of suicide. A stable heart rhythm would not be a safety concern.

DIF: Analyzing REF: p. 99 OBJ: 7.4 TOP: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

NOT: Concepts: Safety