Chapter 12 Diagnosing

Chapter 12  Diagnosing

Complete Chapter Questions And Answers
 

Sample Questions

1.
Which of the following is a correct guideline to follow when composing a nursing diagnosis statement?
A)
Place defining characteristics after the etiology and link them by the phrase “as evidenced by.”
B)
Phrase the nursing diagnosis as a client need.
C)
Place the etiology prior to the client problem and linked by the phrase “related to.”
D)
Incorporate subjective and judgmental terminology.
Ans:
A

Feedback:

Defining characteristics should follow the etiology and be linked by the phrase “as evidenced by” when included in the nursing diagnosis. The nursing diagnosis should be phrased as a client problem or alteration in health state, rather than as a client need. The client problem precedes the etiology and is linked by the phrase “related to.” Avoid using judgmental language and write in legally advisable terms.

2.
In planning the care for a client who has pneumonia, the nurse collects data and develops nursing diagnoses. Which of the following is an example of a properly developed nursing diagnosis?
A)
Ineffective airway clearance as evidenced by inability to clear secretions
B)
Ineffective health maintenance as evidenced by unhealthy habits
C)
Ineffective breathing pattern related to pneumonia
D)
Ineffective therapeutic regimen management due to smoking
Ans:
A

Feedback:

The appropriately written nursing diagnosis is “ineffective airway clearance related to inability to clear secretions.” “Ineffective health maintenance related to unhealthy habits” is incorrect because it shows value judgments by the nurse. “Ineffective breathing pattern related to pneumonia” is incorrectly written because it includes a medical diagnosis. “Ineffective therapeutic regimen management due to smoking” is incorrect because the clause “due to” implies a direct cause-and-effect relationship.

3.
The nurse has identified a number of risk nursing diagnoses in the care of an adolescent who has been admitted to the hospital for treatment of an eating disorder. These risk diagnoses indicate which of the following?
A)
The client is more vulnerable to certain problems than other individuals would be.
B)
The diagnoses present significant risks for the development of medical diagnoses.
C)
The data necessary to make a definitive nursing diagnosis is absent.
D)
The diagnosis has yet to be confirmed by another practitioner.
Ans:
A

Feedback:

Risk nursing diagnoses are clinical judgments that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation. They do not denote a particular link to medical diagnoses nor do they require independent confirmation. Missing data is associated with possible nursing diagnoses.

4.
A client with a new colostomy often becomes short and sarcastic when nurses attempt to teach him about the management of his new appliance. The nurse has consequently documented “Noncompliance related hostility” on the client’s chart. What mistake has the nurse made when choosing and documenting this nursing diagnosis?
A)
Presuming to know the factors contributing to the problem
B)
Identifying a problem that cannot be changed
C)
Identifying a problem without corroborating evidence in the statement
D)
Neglecting to identify potential complications related to the problem
Ans:
A

Feedback:

Multiple factors may underlie the client’s response to education in a complex and emotionally charged situation, such as receiving a new ostomy. As a result, it is likely presumptuous to ascribe the client’s response to hostility. The problem is likely modifiable with a correct approach; the evidence underlying a nursing diagnosis is not normally explicit in the statement itself. The existence of potential complications is not central to the psychosocial nature of this client’s situation.

5.
The nurse has drafted a nursing diagnosis of Imbalanced Nutrition: More Than Body Requirements in the care of moderately obese client. How should the nurse proceed after writing this diagnosis?
A)
Validate the nursing diagnosis
B)
Identify potential complications
C)
Cross-reference the nursing diagnosis with medical diagnoses
D)
Modify interventions based on the diagnosis
Ans:
A

Feedback:

After writing a nursing diagnosis, it is important to verify and validate the diagnosis. This action should precede the modification of the client’s care. Nursing diagnoses do not always correlate with medical diagnoses and not every nursing diagnosis is accompanied by potential complications.