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Fundamentals Nursing Vol 1 3rd Edition By Wilkinson Treas – Test Bank
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Chapter 2. Critical Thinking & Nursing Process
MULTIPLE CHOICE
- Which of the following characteristics do the various definitions of critical thinking have in common? Critical thinking:
| a) | Requires reasoned thought |
| b) | Asks the questions “why” or “how” |
| c) | Is a hierarchical process |
| d) | Demands specialized thinking skills |
ANS: A
The definitions listed in the text as well as definitions contained in Box 2-1 state that critical thinking requires reasoning or reasoned thinking. Critical thinking is neither linear nor hierarchical. The steps involved in critical thinking are not necessarily sequential, wherein mastery of one step is necessary to proceed to the next. Critical thinking is a purposeful, dynamic, analytical process that contributes to reasoned decisions and sound contextual judgments.
(High-level question, answer not stated verbatim)
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Analysis
Difficulty: Moderate
PTS: 1
- A few nurses on a unit have proposed to the nurse manager that the process for documenting care on the unit be changed. They have described a completely new system. Why is it important for the nurse manager to have a critical attitude? It will help the manager to:
| a) | Consider all the possible advantages and disadvantages |
| b) | Maintain an open mind about the proposed change |
| c) | Apply the Nursing Process to the situation |
| d) | Make a decision based on past experience with documentation |
ANS: B
A critical attitude enables the person to think fairly and keep an open mind.
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Comprehension
Difficulty: Moderate
PTS: 1
- The nurse has just been assigned to the clinical care of a newly admitted patient. To know how best to care for the patient, the nurse uses the Nursing Process. Which step would the nurse probably undertake first?
| a) | Make an assessment |
| b) | Make a diagnosis |
| c) | Plan outcomes |
| d) | Plan interventions |
ANS: A
Assessment is the first step of the Nursing Process. The nursing diagnosis is derived from the data gathered during assessment, outcomes from the diagnosis, and interventions from the outcomes.
Nursing Process: Assessment
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Easy
PTS: 1
- Which of the following is an example of practical knowledge? Assume all are true.
| a) | The tricuspid valve is located between the right atrium and ventricle of the heart. |
| b) | The pancreas does not produce enough insulin in type 1 diabetes. |
| c) | When assessing the abdomen, you should auscultate before palpating. |
| d) | Research shows pain medication given intravenously acts faster than medication given by other routes. |
ANS: C
Practical knowledge is knowing what to do and how to do it, such as how to make an assessment. The others are examples of theoretical knowledge, anatomy (tricuspid valve), facts (type 1 diabetes), and research (intravenous pain medication).
(High-level question, answer not stated verbatim)
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Moderate
PTS: 1
- Which of the following is an example of self-knowledge? The nurse thinks, “I know that I:
| a) | Should take the client’s apical pulse for 1 full minute before giving digoxin” |
| b) | Should follow the client’s wishes even though it is not what I would want” |
| c) | Have religious beliefs that may make it difficult to take care of some clients” |
| d) | Need to honor the client’s request not to discuss his health concern with the family” |
ANS: C
Self-knowledge is being aware of your religious and cultural beliefs and values. Taking the pulse is an example of practical knowledge. Following client wishes and honoring client requests are examples of ethical knowledge.
(High-level question, answer not stated verbatim)
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Difficult
PTS: 1
- Which of the following is the most important reason for nurses to be critical thinkers?
| a) | Nurses need to follow policies and procedures. |
| b) | Nurses work with other healthcare team members. |
| c) | Nurses care for clients who have multiple health problems. |
| d) | Nurses have to be flexible and work variable schedules. |
ANS: C
Critical thinking is essential for client care, particularly when the care is complex, involving numerous health issues. Following policies and procedures does not necessarily require critical thinking; working with others or being flexible and working different schedules do not necessarily require critical thinking.
(High level question, answer not stated verbatim)
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Moderate
PTS: 1
- The nurse administering pain medication every 4 hours is an example of which aspect of patient care?
| a) | Assessment data |
| b) | Nursing diagnosis |
| c) | Patient outcome |
| d) | Nursing intervention |
ANS: D
Interventions are activities that will help the patient achieve a goal, such as administering pain-relieving medication. An example of assessment data might be: “Patient reports pain is a 5 on a 1 to 10 scale.” The nursing diagnosis would be “pain.” The nurse might define the patient outcome in this scenario as, “The patient will state the level of pain is less than 4.”
(High-level question, answer not stated verbatim)
Nursing Process: Interventions
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Moderate
PTS: 1
- How does a nursing diagnosis differ from a medical diagnosis? A nursing diagnosis is:
| a) | Terminology for the client’s disease or injury |
| b) | A part of the client’s medical diagnosis |
| c) | The client’s presenting signs and symptoms |
| d) | A client’s response to a health problem |
ANS: D
A nursing diagnosis is the client’s response to actual or potential health problems.
Nursing Process: Diagnosis
Client Need: Safe and Effective Care
Cognitive Level: Knowledge
Difficulty: Easy
PTS: 1
- What do critical thinking and the Nursing Process have in common?
| a) | They are both linear processes used to guide one’s thinking. |
| b) | They are both thinking methods used to solve a problem. |
| c) | They both use specific steps to solve a problem. |
| d) | They both use similar steps to solve a problem. |
ANS: B
Critical thinking and the Nursing Process are ways of thinking that can be used in problem-solving (although critical thinking can be used for other than problem-solving applications). Neither method of thinking is linear. The Nursing Process has specific steps; critical thinking does not.
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Analysis
Difficulty: Difficult
PTS: 1
- A nurse admits a patient to the unit after completing a comprehensive interview and physical examination. To develop a nursing diagnosis, the nurse must now:
| a) | Analyze the assessment data |
| b) | Consult standards of care |
| c) | Decide which interventions are appropriate |
| d) | Ask for the client’s perceptions of her health problem |
ANS: A
The basis of the nursing diagnosis is the assessment data. Standards of care are referred to when establishing nursing interventions. Customizing interventions personalizes nursing care. Asking the patient about her perceptions is a method to validate whether the nurse has chosen the correct nursing diagnosis and would probably have been done during the comprehensive assessment.
Nursing Process: Diagnosis
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Moderate
PTS: 1
- The nurse developed a care plan for a patient to help prevent Impaired Skin Integrity. She has made sure that nursing assistive personnel change the patient’s position every 2 hours. In the evaluation phase of the Nursing Process, which of the following would the nurse do first?
| a) | Determine whether she has gathered enough assessment data |
| b) | Judge whether the interventions achieved the stated outcomes |
| c) | Follow up to verify that care for the nursing diagnosis was given |
| d) | Decide whether the nursing diagnosis was accurate for the patient’s condition |
ANS: B
The evaluation phase judges whether the interventions were effective in achieving the desired outcomes and helped to alleviate the nursing diagnosis. This must be done before examining the Nursing Process steps and revising the care plan.
Nursing Process: Evaluation
Client Need: Safe and Effective Care
Cognitive Level: Analysis
Difficulty: Moderate
PTS: 1
- In caring for a patient with both diabetes and Impaired Skin Integrity (comorbidity), the nurse draws on her knowledge of diabetes and skin integrity. In a spirit of inquiry, she looks up the latest guidelines for providing skin care and includes them in the plan of care. The nurse provides skin care according to the procedural guidelines and begins regular monitoring to evaluate the effectiveness of the interventions. The nurse has demonstrated:
| a) | Full-spectrum nursing |
| b) | Critical thinking |
| c) | Nursing Process |
| d) | Nursing knowledge |
ANS: A
Full-spectrum nursing involves the use of critical thinking, nursing knowledge, Nursing Process, and patient situation. Although the other answers are important for planning and delivering nursing care, they do not reflect all the nurse has demonstrated.
(High level question, answers not stated verbatim)
Nursing Process: Not applicable
Client Need: PHSI
Cognitive Level: Analysis
Difficulty: Difficult
PTS: 1
- It is important for nurses to be critical thinkers because:
| a) | All clients are unique and have individual needs and differences |
| b) | All nursing actions are based on theoretical knowledge |
| c) | Nurses choose their actions primarily by following professional guidelines |
| d) | Nurses provide care based on individual client preferences |
ANS: A
All clients are unique and have individual differences. Nursing actions are not solely based on theoretical knowledge. Actions are based on theoretical knowledge, practical knowledge, and self-knowledge. Following guidelines does not usually require critical thinking, and guidelines often do not offer adequate help in managing complex situations. Client preferences are certainly included in the plan of care but they do not cover the broad spectrum of being a critical thinker—it does not require critical thinking merely to do what the client prefers.
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Comprehension
Difficulty: Moderate
PTS: 1
- A full-spectrum nurse uses a critical-thinking model to organize her thinking when caring for a patient. The nurse realizes she lacks some facts about the patient’s pathophysiology, so she makes sure to use a credible source for the information. She considers the alternatives for action, then again looks up some information. Before deciding what to do, she thinks about the patient’s family situation. What aspect of a critical-thinking model does this best illustrate? The nurse is:
| a) | Following model guidelines for specific interventions |
| b) | Using linear processes to think critically |
| c) | Moving back and forth between steps, and not thinking sequentially |
| d) | Using self-knowledge in the decision-making process |
ANS: C
Critical thinking is not sequential, and critical-thinking models are not applied sequentially. Critical-thinking models do not proceed from top to bottom, nor are they linear. Nurses may jump back and forth between the various steps. Critical-thinking models do not prescribe guidelines for specific interventions. Although self-knowledge may be used as part of a decision-making process, this is not the best answer to complete the statement. The only way self-knowledge is involved in this scenario is that the nurse recognizes that she is lacking some information/knowledge.
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Difficult
PTS: 1
- Which is the best example of a critical-thinking attitude? The nurse:
| a) | Has extensive knowledge of principles and theories |
| b) | Has a lively curiosity and enjoys discovering new ways of doing things |
| c) | Applies the problem-solving process he was taught in nursing school |
| d) | Responds to patients mainly on the basis of what is socially approved |
ANS: B
Attitudes are more akin to feelings and traits than to intellectual skills. Therefore, extensive knowledge is not a good example of an attitude. Attitudes are addressed in nursing school but it is unlikely that one can “teach” attitudes. A problem-solving process does necessarily require critical thinking; moreover, applying a process simply because one learns it in school would mean the person is not demonstrating an attitude of intellectual independence. Society and culture do help to form attitudes, but that is not the same as basing actions on what is socially approved. Again, that would not demonstrate independent thinking or any of the other critical-thinking attitudes.
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Difficult
PTS: 1
- What is the best description of the Nursing Process? The Nursing Process is:
| a) | A way to create nursing knowledge for use in practice |
| b) | A systematic view of a specific phenomenon in nursing |
| c) | A linear process for providing nursing care |
| d) | A systematic process for the delivery of nursing care |
ANS: D
The Nursing Process is central to nursing care. It is a systematic problem-solving process that guides all nursing actions. The process does not create knowledge. Knowledge is created through theoretical and practical research. The Nursing Process is not a view of a specific phenomenon. Finally, the Nursing Process is not linear; the steps are reflexive and overlapping.
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Comprehension
Difficulty: Easy
PTS: 1
- The nurse is caring for a client with heart failure. She begins to obtain the client’s history and vital signs and then listens to breath sounds. The nurse is practicing which aspect of the Nursing Process?
| a) | Assessment |
| b) | Planning interventions |
| c) | Planning outcomes |
| d) | Evaluation |
ANS: A
Obtaining the history, auscultating breath sounds, and obtaining vital signs are part of the assessment process. In the assessment step, the nurse gathers patient data and information. In the planning interventions step, the nurse chooses nursing activities aimed at meeting patient goals (and thus relieving the patient’s problem). In the planning outcomes phase, the nurse and patient identify goals for the patient’s health—expected or desired outcomes of the care. After performing nursing activities, in the evaluation stage the nurse reassesses the patient to determine whether goals have been met.
Nursing Process: Assessment
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Moderate
PTS: 1
- The nurse is caring for a client with skin breakdown of the coccyx area. The physician has ordered a medication to be applied to the area. In applying the medication, the nurse is practicing which aspect of the Nursing Process?
| a) | Assessment |
| b) | Planning interventions |
| c) | Implementation |
| d) | Evaluation |
ANS: C
Application of a medication to the coccyx area is an “action.” The nurse both plans and carries out the intervention. The nurse carries out (and records) interventions in the implementation phase. Evaluation is done after the plan (or nursing action) is implemented.
Nursing Process: Implementation
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Moderate
PTS: 1
- The nurse documents in the client plan of care that the wound treatment to the client’s left foot has resulted in wound healing. She removed the Skin Integrity diagnosis from the plan of care. The nurse is using which aspect of the Nursing Process?
| a) | Assessment |
| b) | Evaluation |
| c) | Planning outcomes |
| d) | Planning interventions |
ANS: B
Documenting nursing interventions and a patient’s immediate responses (e.g., expressed pain, became restless) is done in the implementation stage. However, in this scenario the nurse also documented that the wound was healing and she removed the nursing diagnosis from the care plan. This demonstrates evaluation.
Nursing Process: Evaluation
Client Need: Safe and Effective Care
Cognitive Level: Analysis
Difficulty: Difficult
PTS: 1
- The nurse enters a room to find the client sitting up in the chair, crying. The nurse best displays a critical-thinking attitude, as well as a caring attitude, by:
| a) | Telling the client that she’ll be back to chat after she sees her other clients |
| b) | Calling the family to come and sit with the client |
| c) | Trying to determine the reasons for the client’s crying |
| d) | Placing a “do not disturb” sign on the door to protect the client’s privacy |
ANS: C
The nurse should try to find out why the client is crying so that she may intervene appropriately and correctly. Postponing talking with the client does not assist the client nor does it enable the nurse to make an appropriate intervention. Telling the client she’ll be back may cause the client to feel that her needs are less important. Calling the family may be helpful to the client once the nurse identifies why the client is crying. However, depending on the reason, the family may not be at all helpful. A “do not disturb” sign, without obtaining more information, may isolate the client. Upon further exploration, the nurse may discover that the client is already feeling alone and that she does not want or need privacy right now.
Nursing Process: Implementation
Client Need: PSI
Cognitive Level: Application
Difficulty: Moderate
PTS: 1
- Select the answer that best completes the following statement: The primary purpose of employing the full-spectrum nursing model is to:
| a) | Assist nurses in testing psychomotor skills |
| b) | Have a positive effect on a client’s health outcomes |
| c) | Adequately use all aspects of the Nursing Process |
| d) | Assist nurses in completing their work on time |
ANS: B
The question is asking for the best answer to complete the statement. The best answer is “to have a positive effect on a client’s health outcomes,” which is also a goal of nursing in general. The full-spectrum model may assist nurses in performing psychomotor skills and even in completing their work on time—especially when something unexpected occurs. However, that is not the focus of the model. Full-spectrum nursing would likely improve the nurse’s problem-solving ability (as in the Nursing Process); however, that is not the end purpose of full-spectrum nursing. It is merely a means to achieving the purpose of positively affecting health outcomes.
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Comprehension
Difficulty: Moderate
PTS: 1
- The nurse has gathered her assessment data and notes several significant changes in the client’s health status. The client’s weight has increased by 5 lb over the past 24 hours, he is short of breath, and crackles are auscultated at both lung bases. To which step of the Nursing Process should the nurse proceed after organizing these data?
| a) | Diagnosis |
| b) | Planning |
| c) | Implementation |
| d) | Evaluation |
ANS: A
After gathering and analyzing the assessment data, the nurse should next formulate a nursing diagnosis. The other options are not done until after the problem has been diagnosed. The problem is used to plan goals, which are then used to plan interventions. After implementing the intervention(s), evaluation is done to identify change in health status and determine whether goals have been met.
Nursing Process: Diagnosis
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Moderate
PTS: 1
MULTIPLE RESPONSE
- Which aspects of healthcare are affected by a client’s culture? Select all that apply.
| a) | How the client views healthcare |
| b) | How the client views illness |
| c) | Whether insurance will pay for healthcare services |
| d) | The types of treatments the client will accept |
| e) | When the client will seek healthcare services |
| f) | The environment in which the healthcare services are provided |
| g) | The ease of accessibility of healthcare services |
ANS: A, B, D, E
Culture impacts clients’ views of health and healthcare. It influences how they will define illness, when they will seek healthcare, and what treatments are acceptable in their culture. How services are paid for is related to social environment and economic status. Regardless of culture, anyone can be affected by previous healthcare experiences, the environment in which healthcare is provided, and accessibility of services.
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Knowledge
Difficulty: Moderate
PTS: 1
- Caring is a central concept in nursing that involves which of the following? Select all that apply.
| a) | Treating all clients with a similar disease in exactly the same way |
| b) | Responding compassionately to client needs |
| c) | Acting in ways to preserve human dignity |
| d) | Connecting with others to give and receive help |
| e) | Using active listening |
ANS: B, C, D, E
Treating all clients in exactly the same way just because they share similar disease processes does not consider their uniqueness nor honor their personhood—and thus does not reflect caring. The other options are all aspects of caring.
Nursing Process: Not applicable
Client Need: PSI
Cognitive Level: Analysis
Difficulty: Moderate
PTS: 1
Chapter 4. Nursing Process: Diagnosis
MULTIPLE CHOICE
- 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
- 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
- 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
- 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
- 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
- What is wrong with the following diagnostic statement? “Impaired Physical Mobility related to laziness and not having appropriate shoes.” The statement is:
| a) | Judgmental |
| b) | Too complex |
| c) | Legally questionable |
| d) | Without supportive data |
ANS: A
“Lazy” implies criticism of the client and therefore is judgmental. There need to be several (certainly more than two) etiological factors for the statement to be complex. There is no blame implied or harm resulting, so the statement is not legally questionable. There is no minimum “amount” of supportive data for a diagnosis and the stated etiology related to the nursing diagnosis. No supportive data are given in the stem of the question, so you could not choose “lack of data” as the best answer because all the options lack data as far as you can tell from the information given in the question. In addition, it is not necessary to include supportive data in the diagnostic statement (although some do prefer to use AMB and include defining characteristics).
Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: Safe and Effective Nursing Care
Cognitive Level: Analysis
PTS: 1
- When making a diagnosis using NANDA-I, which of the following provides support for the diagnostic label you choose?
| a) | Etiology |
| b) | Related factors |
| c) | Diagnostic label |
| d) | Defining characteristics |
ANS: D
The defining characteristics are the signs and symptoms that must be present to support any given nursing diagnosis. The etiology and related factors are the causes of or contributing factors to the problem. The diagnostic label is the name NANDA-I has given the problem; it is chosen based on the presence of defining characteristics.
Difficulty: Easy
Nursing Process: Diagnosis
Client Need: Safe and Effective Nursing Care
Cognitive Level: Comprehension
PTS: 1
- Based only on Maslow’s Hierarchy of Needs, which nursing diagnosis should have the highest priority?
| a) | Self-Care Deficit |
| b) | Risk for Aspiration |
| c) | Impaired Physical Mobility |
| d) | Functional Urinary Incontinence |
ANS: B
Highest priority is given to problems that are life threatening or that could be destructive to the client. Safety is most basic in Maslow’s hierarchy. Even though Risk for Aspiration is not an actual problem, it poses the most immediate life-threatening risk to the client; nursing interventions must be performed to prevent it from becoming an actual problem.
Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: PHSI
Cognitive Level: Analysis
PTS: 1
- Which of the following describes the most important use of making a nursing diagnosis? Assume all are true.
| a) | Differentiates the nurse’s role from that of the physician |
| b) | Identifies a body of knowledge unique to nursing |
| c) | Helps nursing develop a more professional image |
| d) | Describes the client’s needs for nursing care |
ANS: D
The benefits to nurses and nursing are that nursing diagnoses differentiate the nurse’s role, they identify a unique body of nursing knowledge, and some think they help nursing to develop a more professional image. However, the primary goal of nursing is to serve the good of the patient. Therefore, the most important use of a diagnosis is to specifically identify the client’s needs for quality nursing care.
Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: Safe and Effective Nursing Care
Cognitive Level: Analysis
PTS: 1
- Which of the following is a criticism of standardized nursing diagnoses developed by NANDA-I?
| a) | There is little research to support nursing diagnosis labels. |
| b) | A perfect nursing diagnosis must be written for it to be useful. |
| c) | Standardized diagnoses are not included in all states’ nurse practice acts. |
| d) | Other professions do not recognize nursing diagnoses. |
ANS: A
Best practice is evidence-based practice; that is, it is developed through sound, scientific research. Research is currently being conducted, but many of the diagnoses are not research based. A perfect nursing diagnosis is impossible to write, so that is not an issue. Having standardized nursing diagnoses recognized in state practice acts or by other professions has nothing to do with the value of the NANDA-I taxonomy.
Difficulty: Difficult
Nursing Process: Diagnosis
Client Need: Safe and Effective Nursing Care
Cognitive Level: Knowledge
PTS: 1
- Which of the following most accurately describes nursing diagnoses? A nursing diagnosis:
| a) | Supports the nurse’s diagnostic reasoning |
| b) | Supports the client’s medical diagnosis |
| c) | Identifies a client’s response to a health problem |
| d) | Identifies a client’s health problem |
ANS: C
Nursing diagnoses are statements that nurses use to describe a client’s physical, mental, emotional, spiritual, and social response to disease, injury, or other stressor. Diagnostic reasoning is used to identify the appropriate nursing diagnosis; it is not meant to “support” the diagnosis. A health problem is a condition that requires intervention to promote wellness or prevent illness; it is sometimes, but not always, a nursing diagnosis. Nursing diagnoses are not medical diagnoses.
Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: Safe and Effective Nursing Care
Cognitive Level: Analysis
PTS: 1
- The diagnostic label, or patient problem, is used primarily to suggest:
| a) | Client goals |
| b) | Cue clusters |
| c) | Interventions |
| d) | Etiology |
ANS: A
As a general rule, the problem suggests goals for client outcomes. The etiology suggests interventions. Cue clusters support whether the correct nursing diagnosis has been identified.
Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: Safe and Effective Nursing Care
Cognitive Level: Knowledge
PTS: 1
- Which nursing diagnosis is written in the correct format when using the NANDA-I taxonomy?
| a) | Bowel Obstruction related to recent abdominal surgery AMB: nausea, vomiting, and abdominal pain |
| b) | Inability to Ingest Food related to imbalanced nutrition: less than body requirements A.M.B. inadequate food intake, weight less than 20% under ideal body weight |
| c) | Impaired Skin Integrity related to physical immobility AMB skin tear over sacral area |
| d) | Caregiver Role Strain related to alienation from family and friends AMB 24-hour care responsibilities |
ANS: C
The components of NANDA-I nursing diagnosis might include the following four parts: diagnostic label, defining characteristics, related factors, and risk factors. “Impaired Skin Integrity . . .” has the problem statement, etiology, and symptoms. For “Bowel Obstruction . . .” the problem is a medical diagnosis. The cause-and-effect order of “Inability to Ingest Food . . .” is incorrect; it starts with the etiology. The etiology and symptoms (A.M.B.) of “Caregiver Role Strain . . .” are reversed (alienation from family and friends are the symptoms that support the diagnosis).
Difficulty: Difficult
Nursing Process: Diagnosis
Client Need: Safe and Effective Nursing Care
Cognitive Level: Application
PTS: 1
- Which nursing diagnosis is written in the correct format?
| a) | Imbalanced Nutrition: Less than Body Requirements related to body weight less than 20% under ideal weight |
| b) | Ineffective Airway Clearance related to increased respiratory rate and irregular rhythm |
| c) | Impaired Swallowing related to absent gag reflex |
| d) | Excess Fluid Volume related to 3 lb weight gain in 24 hours |
ANS: C
The etiology should describe what is causing or contributing to the problem. The etiologies for Ineffective Airway Clearance, Impaired Swallowing, and Excess Fluid Volume describe signs or symptoms rather than causal factors.
Difficulty: Difficult
Nursing Process: Diagnosis
Client Need: Safe and Effective Nursing Care
Cognitive Level: Analysis
PTS: 1
- The patient shows the necessary defining characteristics, and the nurse has diagnosed Decisional Conflict related to unclear personal values and beliefs. What essential action should the nurse take to help ensure the accuracy of this diagnosis?
| a) | Ask a more experienced nurse to confirm it. |
| b) | Request a social worker interview the patient. |
| c) | Ask the patient to confirm the diagnosis. |
| d) | Read about Decisional Conflict in the NANDA-I handbook. |
ANS: C
After identifying problems and etiologies (which this nurse has done), the nurse should verify them with the patient to help ensure that her conclusions are accurate. If the patient does not agree that he has Decisional Conflict, the nurse might interview him more in depth to clarify the meaning of the data. Certainly the nurse could ask another nurse’s opinion, but that is not essential. It would make no sense to have a social worker interview the patient unless the situation remains unclear even after confirming with the client. If the nurse did have adequate theoretical knowledge of Decisional Conflict for this patient, she should have been informed by reading the NANDA-I handbook before making the diagnosis. If the patient does not confirm the diagnosis, and the nurse concludes the diagnosis is in error, she might then reread the NANDA-I guide.
Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: Safe and Effective Nursing Care
Cognitive Level: Application
PTS: 1
- The client’s weight is appropriate for his height. His laboratory values and other assessments reflect normal nutritional status. However, he has told the nurse, “I probably eat a little too much red meat. And what is this I hear about needing omega 3 oils in my diet? I don’t like to take supplements, and I think I could really improve my nutrition.” Which of the following nursing diagnoses should the nurse use?
| a) | Balanced Nutrition |
| b) | Possible Imbalanced Nutrition: Less Than Body Requirements |
| c) | Risk for Imbalanced Nutrition: Less Than Body Requirements |
| d) | Readiness for Enhanced Nutrition |
ANS: D
You will use a wellness diagnosis when a person’s present level of wellness is effective, and when the person wants to move to a higher level of wellness—in this case, a higher level of nutrition. The format for a wellness diagnosis is “Readiness for Enhanced. . . .” Use a possible diagnosis when you have enough data to suspect a problem but need more data to support a diagnosis. Use a risk diagnosis when there are risk factors for a problem.
Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: Safe and Effective Nursing Care
Cognitive Level: Application
PTS: 1
- The patient verbalizes an overwhelming lack of energy. He says, “I still feel exhausted even after I sleep. I feel guilty when I can’t keep up with my usual daily activities or sleep during the day. I’ve been a little depressed lately, too.” The patient seems to have difficulty concentrating, but has no apparent physical problems. Which of the following diagnoses best describes his health status?
| a) | Fatigue related to depression |
| b) | Fatigue related to difficulty concentrating |
| c) | Guilt related to lack of energy |
| d) | Chronic confusion related to lack of energy |
ANS: A
The diagnosis that best describes the overall health status is Fatigue. The only cue that might cause Fatigue is depression. You cannot use depression as the problem because it is a medical diagnosis, and it is not a NANDA-I label. The other cues (difficulty concentrating, lack of energy, and guilt) are symptoms of Fatigue, not etiologies. These diagnoses would lead the nurse to focus on dealing with guilt and confusion, so the source of the Fatigue would not be addressed.
Difficulty: Difficult
Nursing Process: Diagnosis
Client Need: Safe and Effective Nursing Care
Cognitive Level: Application
PTS: 1
- The nurse documents in the progress notes: “Admitted to emergency department accompanied by wife. Patient is alert and oriented, blood pressure is 120/80 mm Hg, and pulse is 80 beats/min. The patient is anxious. He becomes nervous and when asked about his smoking history.” Which statement from the nurse’s note is the best example of an inference?
| a) | Blood pressure reading 120/80 mm Hg |
| b) | Patient is accompanied by wife. |
| c) | Patient has a history of smoking. |
| d) | The patient is anxious. |
ANS: D
The inference in this item is that the patient is anxious. The nurse observes that the patient is nervous and shaky. She can document these observations but she cannot infer that these observations mean that the patient has anxiety. Blood pressure and patient accompaniment by wife are objective data. History of smoking is subjective data.
Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: PHSI
Cognitive Level: Analysis
PTS: 1
- Which statement made by the nurse is an example of stereotyping?
| a) | “Be sure to take your shoes off when entering a Japanese family’s home.” |
| b) | “Patients with type 1 diabetes do not make insulin; therefore, they will need to take insulin regularly.” |
| c) | “The patient in room 3 cries every time she gets out of bed. She needs to understand that getting out of bed is helping her.” |
| d) | “My 2-year-old child never had a temper tantrum. I don’t understand why the 2-year-old child in room 4 is having one.” |
ANS: A
Stereotypes are judgments and expectations about an individual based on the personal beliefs one may have about a specific group. The statement to remove shoes in a Japanese family’s home is stereotyping this particular culture. Patients with type 1 diabetes will need insulin therapy, as this is a medical treatment for all patients with diabetes. The comment related to the patient in room 3 needing to get out of bed is judgmental. The example of the 2-year-old demonstrates a bias, as the nurse is reflecting her opinion of this 2-year-old based on her personal opinion.
Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: PHSI
Cognitive Level: Analysis
PTS: 1
- Which of the following is the best example of a nursing diagnosis statement?
| a) | Pain related to appendicitis |
| b) | Fractured left leg related to impaired mobility |
| c) | Impaired mobility related to fractured left leg |
| d) | Acute pain related to out of bed activities |
ANS: D
Each of these nursing diagnoses contains a problem and etiology. A problem describes the human response to a health problem and should be written in NANDA-I format. The etiology contains factors that cause or contribute to the problem and should direct nursing interventions. Acute pain is a nursing diagnosis because it is a human response to a health problem. The etiology, out of bed activities, is an example of a contributing factor that the nurse can direct and for which she can make nursing interventions. Pain related to appendicitis is not descriptive of pain nor is appendicitis a nursing etiology; it is a medical diagnosis. Fractured left leg is a medical diagnosis and cannot be used as a nursing diagnosis. Impaired mobility is not appropriate because a medical diagnosis is used in the etiology.
Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: PHSI
Cognitive Level: Analysis
PTS: 1
- Which of the following reflects the most accurate use of an etiology?
| a) | Knowledge deficit related to abdominal ultrasound |
| b) | Knowledge deficit related to incorrect use of walker |
| c) | Knowledge deficit related to diabetes |
| d) | Knowledge deficit related to age |
ANS: B
Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: PHSI
Cognitive Level: Analysis
Etiologies contain factors that cause, contribute to, or create a risk to the health problem. These contributing factors can be independently acted upon by a nurse. Knowledge deficit (abdominal ultrasound) describes the knowledge problem; lack of prenatal teaching describes the likely reason for the Knowledge deficit and is a factor the nurse can address independently. Knowledge deficit (use of walker) has no etiology. Knowledge deficit (use of walker) r/t muscle weakness is illogical. Muscle weakness may be interfering with the ability to use the walker; however, it is not a factor contributing to the problem of Knowledge deficit. Knowledge deficit related to diabetes is incorrect because diabetes is a medical diagnosis that a nurse cannot act upon without direction or PCP orders. Age is not specified in the example and is demographic data that cannot be altered; this etiology is too vague and general to be useful.
Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: PHSI
Cognitive level: Analysis
PTS: 1
- After identifying problems and etiologies and prior to writing a nursing diagnosis statement, the nurse would:
| a) | Verify the nursing diagnosis with the patient |
| b) | Verify information with the primary care provider |
| c) | Check the medical diagnosis for consistency in treatments |
| d) | Review the data and the diagnosis with another nurse |
ANS: A
After identifying problems and etiologies, the nurse must verify them with the patient. A diagnostic statement is an interpretation of the data and the patient’s interpretation may not be the same as that of the nurse. Verifying information with the primary care provider does not assist the nurse in developing a plan of care based on nursing diagnoses and interventions. Checking the medical diagnosis for consistency in treatments does not assist the nurse in tailoring the nursing diagnosis to individual patient needs, although when planning care, the nurse does need to be certain that nursing interventions do not conflict with medical therapies. Reviewing the data and the diagnosis with another nurse may reaffirm the nurse’s conclusions; however, the diagnosis still needs to be verified with the patient.
Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: PHSI
Cognitive Level: Comprehension
PTS: 1
- Which statement related to prioritizing patient problems is most accurate?
| a) | Nurses must resolve one problem before addressing another problem. |
| b) | Nurses prioritize problems in order of urgency. |
| c) | Actual problem always take priority over risk problems. |
| d) | Nurses give the highest priority to problems that the patient thinks are most important. |
ANS: B
Patients often have more than one problem, so the nurse must use nursing judgment to decide which to address first and which can wait. Nurses do not need to resolve one problem before attending to another. Actually, in many circumstances nurses may be assessing and intervening for several problems at the same time. Prioritization implies a ranking of urgency to patient problems according to the degree of threat they pose to the patient’s life or to the immediacy with which treatment is needed. Highest priority is always given to life-threatening problems; however, not all patient problems are life threatening. Frequently, nurses encounter risk problems that may earn a higher priority ranking than an actual problem. Giving priority to problems tht the patient thinks are most important is important, providing this does not conflict with the basic/survival needs or medical treatments.
Difficulty: Easy
Nursing Process: Diagnosis
Client Need: PHSI
Cognitive Level: Knowledge
PTS: 1
- The nurse receives the following report on four patients on the medical-surgical unit. Which patient will the nurse attend to first?
| a) | Gait unsteady, uses walker, needs 2-person assist with ambulation |
| b) | Abdominal wound is draining foul-smelling fluid, incision margins are red, heart rate 100 beats/min |
| c) | Blood pressure 90/50 mm Hg, heart rate 40 beats/min, rates chest pain at 8 on a 0 to 10 pain scale |
| d) | Verbalizes history of migraine headaches, eyes closed during assessment interview |
ANS: C
Unstable vital signs with chest pain is of the highest priority because these symptoms may be life threatening. These instabilities must be addressed at once. Although an unsteady gait places a patient at risk for falls, this answer indicates that the patient uses a walker and 2-person assist. The draining wound is infected; however, this can be addressed with medications. Infections do not usually progress rapidly (i.e., as compared with chest pain). The wound symptoms are not immediately life threatening. A patient with a history of migraine headaches is not a priority at this time, although the patient’s pain should be relieved as quickly as possible after dealing with the highest priority problem(s).
Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: Safe and Effective Nursing Care
Cognitive Level: Application
PTS: 1
MULTIPLE RESPONSE
- The benefits for nursing practice in using a standardized nursing language include which of the following? Select all that apply.
| a) | Define and communicate nursing knowledge |
| b) | Assist the nurse in understanding medical diagnoses |
| c) | Facilitate nursing research |
| d) | Help nurses provide consistent interventions for all patients |
ANS: A, C
Standardized nursing languages are a comparatively recent attempt to bring clarity to communication about nursing knowledge and nursing thinking. A standardized language can define, communicate, and expand nursing knowledge, increase visibility and awareness of nursing interventions, facilitate research, and improve patient care by providing better communication among nurse and other healthcare providers. A medical diagnosis describes a disease, illness, or injury. Its purpose is to identify a pathology so that appropriate medical treatment can be given. Nurses deliver nursing care and actions in different ways for different patients. All patients do not have the same needs and problems; therefore, care is planned on an individual basis.
Difficulty: Easy
Nursing Process: Diagnosis
Client Need: PHSI
Cognitive Level: Knowledge
PTS: 1
- Which of the following regarding nursing diagnosis are accurate? Select all that apply.
| a) | Provide the basis for nursing interventions |
| b) | Are validated with patient and family when possible |
| c) | Have historically been well substantiated by research |
| d) | Are descriptions of pathological disease processes |
ANS: A, B
Nursing diagnosis is the second step in the Nursing Process. It is the link between the preceding assessment data and all future phases. It further provides the basis for planning client-centered goals and interventions. When possible, the nursing diagnosis as well as all other steps in the Nursing Process should be validated with the patient. The diagnostic statement is written after all data are collected and reflects the nurse’s clinical reasoning in establishing the nursing problem. Nursing diagnoses are human responses to health problems, whereas medical diagnoses establish disease processes. Many nursing diagnoses have been verified and established through research; however, this has not been a historical strength of the taxonomy. This continues to be a criticism of nursing diagnosis.
Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: PHSI
Cognitive Level: Analysis
PTS: 1
- Which of the following nursing diagnosis statements, using the three-part format (PES), are correct? Select all that apply.
| a) | Chronic pain related to osteoarthritis AMB rates pain at 8 on a 0 to 10 pain scale and has difficulty with ambulation. |
| b) | Ineffective airway clearance related to excessive mucus AMB cough, shortness of breath, change in respiratory rate and rhythm |
| c) | Caregiver role strain related to increasing care needs AMB wife states, “He is just getting too heavy for me to lift” |
| d) | Anxiety (moderate) related to cardiac catheterization AMB crying and yelling at family members |
ANS: B, C
The ineffective airway clearance and caregiver role strain statements contain all components of a correctly written nursing diagnosis statement. The problems are stated in correct NANDA-I format and reflect a patient response to a health problem. The connecting “related to” statements reflect etiologies that cause or contribute to the health problem and can direct nursing interventions. The AMBs reflect signs and symptoms that have validated the patient response to the health problem.
The statement beginning with “Chronic pain” contains an etiology that is a medical diagnosis and cannot be used by the nurse to act on independently. The anxiety statement contains an etiology that describes a diagnostic procedure and cannot be independently acted on by a nurse.
Difficulty: Difficult
Nursing Process: Diagnosis
Client Need: PHSI
Cognitive Level: Analysis
PTS: 1
COMPLETION
- Using Maslow’s Hierarchy of Needs, rank the following nursing diagnoses in order of importance, beginning with the highest-priority diagnosis. (Enter using the following format: 1, 2, 3, 4)
1) Anxiety
2) Risk for infection
3) Disturbed body image
4) Sleep deprivation
ANS:
4, 2, 1, 3
In Maslow’s hierarchy, physiological needs and safety are the highest priority. Sleep is a basic physiological need. Infection can threaten physical health. In this question, infection is not present; therefore, there is only a risk for it. Sleep Deprivation is an immediate problem that affects general physical, mental, and emotional health. Neither Anxiety nor Disturbed Body image is a physiological or safety need. Anxiety is a more immediate need than is Disturbed Body Image; therefore, it probably deserves a higher ranking. Remind students that the ranking would depend on the severity of each problem, which is not known by the labels alone.
Difficulty: Difficult
Nursing Process: Diagnosis
Client Need: Safe and Effective Nursing Care
Cognitive Level: Analysis
PTS: 1
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