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The qualifiers of a nursing diagnosis are:
a. Judgment, continuum of health states, assessment, interventions, and problem.
b. Deficient, impaired, syndrome, risk factors, etiology.
c. Etiology, syndrome, risk, wellness, impaired
.d. Deficient, impaired, decreased, ineffective, and compromised.
Rationale: The qualifiers of nursing diagnosis are deficient, impaired, decreased,ineffective, and compromised.
Consider the following nursing diagnosis: Ineffective Breathing Pattern related to respiratory musclefatigue as evidenced by use of accessory muscles. Which part represents the etiology for this diagnosis?
a. Ineffective Breathing Pattern
b. Respiratory muscle fatigue
c. Use of accessory muscles
d. Related to
Rationale: The etiology component identifies one or more probable causes of thehealth problem. Respiratory muscle fatigue is a probable cause of the diagnosis.Ineffective breathing pattern is not a diagnostic label. Related to represents thatthis is a relationship. Use of accessory muscles is a defining characteristic
A collaborative (multidisciplinary) problem is indicated instead of a nursing or medical diagnosis
:a. If both medical and nursing interventions are required to treat the problem
.b. When no medical diagnosis (disease) can be determined
.c. In cases where nursing interventions are the primary actions required to treat the problem.
d. When independent nursing actions can be utilized to treat the problem.
a.Rationale: A collaborative (multidisciplinary) problem is indicated when bothmedical and nursing interventions are needed to prevent or treat the problem. Ifnursing care alone (whether that care involves independent or dependent nursingactions) can treat the problem, a nursing diagnosis is indicated. If medical carealone can treat the problem, a medical diagnosis is indicated.
Medical diagnosis refers to the disease process, and the pathophysiology processes. Nursingdiagnosis refers to
:a. Diagnosis listed in NANDA
.b. The human response to medical treatment.
c. Monitoring the client’s condition and preventing development of the potential complication.
d. A statement of nursing judgment and refers to a condition that physicians, by virtue, of theireducation, experience, and expertise are licensed to treat.
Rationale: Nursing diagnoses describe the human response, a client’sphysical, sociocultural, psychologic, and spiritual responses to an illnessor a health problem.
Which of the following is stated in the format of a collaborative problem?
a. Risk for decubitus ulcer related to immobility
b. Complication of Immobility: Decubitus Ulcer
c. Decubitus ulcer related to immobility
d. Potential Complication of Immobility: Decubitus Ulcer
Rationale: Collaborative problems are potential problems that nurses manageusing both independent and physician-prescribed interventions. A risk diagnosis isnot a collaborative problem. Decubitus ulcer related to immobility is not stated inthe form of a nursing diagnosis. Complication of Immobility: Decubitus Ulcer isnot stated in the form of a nursing diagnosis.
The nurse is conducting the diagnosing phase (nursing diagnosis) for a client with a seizure disorder.Which of the following elements exists between data analysis and formulating the diagnostic statement?
a. Estimate the cost of several different approaches
.b. Delineate the client’s problems and strengths
.c. Determine which interventions are most likely to succeed.
d. Assess the client’s needs.
Rationale: In diagnosing, data from assessment are analyzed and problems, risks,and strengths are identified before diagnostic statements can be established.Interventions are more commonly part of the planning and implementing phases ofthe nursing process. Cost is an important consideration but would be estimated inthe planning phase.
The end result of data collection and analysis is
:a. Carrying out the plan of care.
b. Collecting and then analyzing the data
.c. Identifying actual or potential health concerns.
d. Identifying the client’s response to care.
Rationale: The identification of the actual or potential health problems of theclient is the end result of the data assessment.
Readiness for Enhanced Parenting is an example of which type of diagnosis?
a. Two-part diagnosis
b. Wellness diagnosis
c. Health-seeking diagnosis
d. Three-part diagnosis
Rationale: Some diagnostic statements, such as wellness diagnoses and syndromenursing diagnoses, consist of a NANDA label only.
When formulating nursing diagnoses, the nurse needs to examine:
a. Functional Health Patterns
.c. Risks and strengths.
d. Signs and symptoms.
Rationale: One of the first parts of evaluation to perform a nursing diagnosis isFunctional Health Patterns.
When writing a nursing diagnosis, the nurse needs to be able to distinguish a problem from
:a. The signs and symptoms
.b. A cause.
c. A need
.d. The risks.
Rationale: The nurse should state the nursing diagnosis based on a problem ratherthan a need.
Nursing diagnosis is based on patterns:
a. Of an acute incidence
.b. Of NANDA labels.
c. Of an isolated incident.
d. Of behaviors over time.
a.Rationale: Nurses should base diagnoses on patterns of behavior overtime – rather than on an isolated incident.
Taxonomy II (NANDA International, 2005) has three levels. These levels are:
a. Critical thinking skills, resources, and basic nursing knowledge
.b. Illness, interventions, and health promotion
.c. Etiologies, complex factors, and symptoms
.d. Domains, classes, and nursing diagnoses.
Rationale: Taxonomy II (NANDA International, 2005) has three levels. Theselevels are: domains, classes, and nursing diagnoses.