Chapter 4 Nursing Process: Diagnosis

Chapter 4  Nursing Process: Diagnosis

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. Which of the following is an example of a problem that nurses can treat independently?
a)
Hemorrhage
b)
Nausea
c)
Fracture
d)
Infection

ANS: B
A nursing diagnosis (or nursing problem) is a human response to a disease, injury, or other stressor that nurses can identify, prevent, or treat independently. Nausea is the only problem that meets that criterion; all others are medical or collaborative problems.

Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: PHSI
Cognitive Level: Application

PTS: 1

2. Which of the following is an example of a cluster of related cues?
a)
Complains of nausea and stomach pain after eating
b)
Has a productive cough and states stools are loose
c)
Has a daily bowel movement and eats a high-fiber diet
d)
Respiratory rate 20 breaths/min, heart rate 85 beats/min, blood pressure 136/84 mm Hg

ANS: A
A cue is an unhealthy response; a cluster of cues consists of cues related to each other, such as nausea and stomach pain after eating. Productive cough and loose stools are abnormal findings but are not obviously or usually related to each other. Daily bowel movement and high-fiber diet are related but normal responses. The vital signs are also within normal limits.

Difficulty: Difficult
Nursing Process: Diagnosis
Client Need: PHSI
Cognitive Level: Analysis

PTS: 1

3. How does a risk nursing diagnosis differ from a possible nursing diagnosis?
a)
A risk diagnosis is based on data about the patient.
b)
A possible diagnosis is based on partial (or incomplete) data.
c)
Nurses collect the data to support risk diagnoses.
d)
A possible diagnosis becomes an actual diagnosis when symptoms develop.

ANS: B
A possible nursing diagnosis is based on nursing knowledge, intuition, and experience and does not have enough data to support it; it is based on incomplete data. A risk diagnosis describes a problem that may develop in a vulnerable client if nursing care is not initiated to prevent it; it is made when risk factors are present in the data. Nurses collect data to support both risk and possible diagnoses; therefore, this statement does not differentiate them. A risk diagnosis becomes an actual diagnosis when symptoms develop.

Difficulty: Difficult
Nursing Process: Diagnosis
Client Need: Safe and Effective Nursing Care
Cognitive Level: Analysis

PTS: 1

4. Which of the following describes the difference between a collaborative problem and a medical diagnosis?
a)
A collaborative problem is treated by the nurse; a physician is responsible for the treatment of a medical problem.
b)
A collaborative problem is a nursing diagnosis that requires specific orders from a physician; a medical diagnosis directs all nursing care.
c)
A collaborative problem has the potential to become an actual nursing diagnosis; a medical diagnosis rarely changes.
d)
A collaborative problem requires intervention by the nurse and physician or other professional; a medical diagnosis requires intervention by a physician.

ANS: D
Collaborative problems are physiological complications for which a client may be at risk based on her medical diagnosis, medical treatment, or diagnostic studies. A collaborative problem requires monitoring by the nurse and intervention by a physician. A medical diagnosis requires interventions (medications, treatments) by the physician. Medical diagnoses do not direct all nursing care. Collaborative problems have the potential to become medical, not nursing, diagnoses.

Difficulty: Difficult
Nursing Process: Diagnosis
Client Need: Safe and Effective Nursing Care
Cognitive Level: Analysis

PTS: 1

5. Which of the following is the best approach to validate a clinical inference?
a)
Have another nurse evaluate it
b)
Have the physician evaluate it
c)
Have sufficient supportive data
d)
Have the client’s family confirm it

ANS: C
All clinical inferences should be well supported by data. The more reliable the data are that you gather, the more certain you can be that your inference is accurate. Because inferences are nursing diagnoses, it would be inappropriate to have a physician evaluate them. Although another experienced nurse could evaluate the inference, it still needs to be supported by sound and sufficient data. Even clients can validate clinical inferences in some situations; however, adequate supporting data are still needed. Keep in mind that the client’s data might or might not be sufficient to “prove” the inference.

Difficulty: Easy
Nursing Process: Diagnosis
Client Need: Safe and Effective Nursing Care
Cognitive Level: Knowledge

PTS: 1