Chapter 17 Review Qs Book Flashcards
A nursing student is working with a faculty member to identify a nurs-
ing diagnosis for an assigned patient. The student has assessed that
the patient is undergoing radiation treatment, has liquid stool, and
the skin is clean and intact. The student selects the nursing diagnosis
Impaired Skin Integrity. The faculty member explains that the student
has made a diagnostic error for which of the following reasons?
1. Incorrect clustering of data
2. Wrong diagnosis
3. Condition is a collaborative problem
4. Premature ending assessment
2
A nurse conducts an assessment of a 42-year-old woman at a health
clinic. The woman is married and lives in a condo with her husband.
She reports having frequent voiding and pain when she passes urine.
The nurse asks whether she has to go to the bathroom at night, and
the patient responds,
“Yes, usually twice or more. The patient had an
episode of diarrhea 1 week ago. She weighs 300 lb and reports having
difficulty cleansing herself after voiding or passing stool. Which of
the following demonstrate assessment findings that cluster to indicate
the nursing diagnosis Impaired Urination. (Select all that apply.)
1. Age 42
2. Dysuria
3. Difficulty performing perineal hygiene
4. Nocturia
5. Episode of diarrhea
2,4
Review the following nursing diagnoses and identify the diagnoses
that are stated correctly. (Select all that apply.)
1. Offer frequent skin care because of Impaired Skin Integrity
2. Risk of Infection
3. Chronic Pain related to osteoarthritis
4. Activity Intolerance related to physical deconditioning
5. Lack of Knowledge related to laser surgery
2,4
Which of the following best describe a collaborative health prob-
lem? (Select all that apply.)
1. An actual or potential physiological complication that nurses
monitor to detect the onset of changes in a patient’s health status
2. The language medical practitioners use to communicate a
patient’s health problem and associated treatments and response
3. A diagnostic label that classifies a patient’s response to illness so
that all nurses can be familiar with a specific patient’s health care
needs
4. A language used by health care providers to communicate and
consider each other’s unique perspective, so they can better
manage the multiple factors that influence the health of individ-
uals
5. A diagnosis that provides clear direction as to the type of nurs-
ing interventions nurses are licensed to provide independently
1,4
Which of the following is a diagnostic error involving identification
of a goal of care rather than a patient need?
1. Patient obtains social support care related to caregiver stress
2. Fear related to open-heart surgery
3. Acute Pain related to splinting of incision
4. Impaired Family Coping related to insufficient caregiver support
1
A nurse is assigned to a new patient admitted to the medical unit.
The nurse collects a nursing history and interviews the patient.
Place the following steps for making a nursing diagnosis in the cor-
rect order.
1. Consider the context of patient’s health problem and select a
related factor.
2. Review assessment data, noting objective and subjective clinical
information.
3. Cluster clinical data elements that form a pattern.
4. Identify appropriate assessment findings for diagnosis.
5. Identify a nursing diagnosis.
2,3,5,1,4
A nurse interviews and conducts a physical examination of a
patient that includes the following findings: reduced move-
ment of lower leg, reduced range of motion in left knee, and
difficulty turning in bed without assistance. This data set is an
example of:
1. Collaborative data set.
2. Diagnostic label.
3. Related factors.
4. Data cluster.
4
A nurse reviews data gathered regarding a patients response to a diag.
nosis of cancer. The nurse notes that the patient is restless, avoids eye
contact, has increased blood pressure, and expresses a sense of helpless-
ness. The nurse compares the pattern of assessment findings for Anxi-
ety with those of Fear and selects Anxiety as the correct diagnosis. This
is an example of the nurse avoiding an error in? (Select all that apply)
1. Data collection
2. Data clustering
3. Data interpretation
4. Making a diagnostic statement
5. Goal setting
2,3,4
