Nursing Chapter 12 Standard Text Select All That Apply Nonjudgmental

The nurse has completed the initial assessment of a client and has analyzed and clustered the data. What should

the nurse complete next in the diagnostic process?

1. Formulate a diagnosis.

2. Verify the data.

3. Research collaborative and nursing-related interventions.

4. Identify the client’s problem, health risks, and strengths.

Question 16

Type: MCSA

The nurse has formulated the following diagnosis: Activity intolerance, related to weakness and debilitation,

manifested by reports of fatigue after any physical activity. What is the defining characteristic of this label?

1. Activity intolerance

2. Weakness and debilitation

3. Reports of fatigue

4. Physical activity

Question 17

Type: MCSA

A client who has just been diagnosed with pancreatic cancer is quite upset and verbal. The nurse has formulated

the following diagnosis: Anxiety, related to unfamiliarity of disease process, manifested by restlessness and

tachycardia. What is the etiology of this diagnosis?

1. Unfamiliarity of disease process

2. Anxiety

3. Restlessness

4. Tachycardia

Question 18

Type: MCSA

The nurse formulates the nursing diagnosis: Acute pain, related to tissue damage, secondary to infarction,

manifested by pallor, client report, and shallow, rapid breathing for a client experiencing an acute myocardial

infarction. Which collaborative action would be appropriate for this client?

1. Provide a calm, quiet atmosphere in the client’s room.

2. Administer pain medication.

3. Educate the client and family regarding treatment and therapies.

4. Monitor for changes in the client’s condition.

Question 19

Type: MCMA

The nurse has formulated a nursing diagnosis of Impaired skin integrity related to poor hygienic practice,

secondary to current living conditions for a client. Which data did the nurse use to support this diagnosis?

Standard Text: Select all that apply.

1. The client has dry, cracked skin.

2. The client has one large and several smaller open, ulcerated areas on his right leg.

3. The client does not drive.

4. The client states that he does not use alcohol or drugs.

5. The client’s clothes are soiled.

6. The client has obvious body odor.

Question 20

Type: MCSA

The nurse is reviewing information about the formulation of nursing diagnoses. What should the nurse identify as

the area in which nursing diagnoses differ from medical diagnoses and collaborative problems?

1. Mental status of the client

2. Chronic nature of the illness

3. Nursing care focus

4. Prognosis

Question 21

Type: MCMA

The nurse is using the Taxonomy II nursing diagnoses system. What axes should the nurse realize are coded

within this system?

Standard Text: Select all that apply.

1. Gordon’s health pattern groupings

2. Age

3. Time

4. Health status

5. Gender

6. Location

Question 22

Type: MCMA

The nurse is reviewing assessment data collected for a client’s care plan. What criteria should the nurse use when

formulating this client’s nursing diagnoses?

Standard Text: Select all that apply.

1. Nonjudgmental statements

2. Stated in terms of a need

3. Must be legally advisable

4. Cause/effect correctly stated

5. Medical terminology used to describe the cause

6. Diagnosis worded specifically and precisely

Question 23

Type: MCSA

The nurse wants to propose a new nursing diagnosis. What action should the nurse take first?

1. Using the proposed nursing diagnosis when constructing client care plans

2. Getting permission for the proposed nursing diagnosis to be implemented by a nursing facility

3. Submitting the diagnosis to NANDA’s Diagnostic Review Committee

4. Presenting the proposed nursing diagnosis at the local AMA (American Medical Association) meeting.

Question 24

Type: MCMA

The nurse is providing care to a client. Which nursing diagnoses can the nurse apply when providing client care?

Standard Text: Select all that apply.

1. Ineffective Breathing Pattern

2. Risk of Infection

3. Readiness for Enhanced Nutrition

4. Readiness for Enhanced Family Coping

5. Anxiety

Question 25

Type: MCMA

The nurse is using the PES model to write a nursing diagnosis. Which nursing diagnoses demonstrate that the

nurse used this model appropriately?

Standard Text: Select all that apply.

1. Ineffective coping related to depression as evidenced by suicide attempt

2. Noncompliance (DASH diet) related to denial of having disease

3. Risk for infection related to recent surgery

4. Nutrition less than adequate related to anxiety as evidenced by weight loss of ten pounds

5. Ineffective Breathing Pattern as evidenced by cyanotic lips

New Questions:

Question 26

Type: MCMA

The nurse is preparing to formulate nursing diagnoses for a client desiring information to help with chronic low

back pain. Which human response patterns should the nurse keep in mind when formulating the diagnoses for this

client?

Standard Text: Select all that apply.

1. Moving

2. Choosing

3. Perceiving

4. Anticipating

5. Communicating

Question 27

Type: MCMA

The nurse formulates nursing diagnoses for a client with chronic renal failure. Which statements indicate the

nurse appropriately used a two-part format?

Standard Text: Select all that apply.

1. Pruritis related to toxin build-up in the blood

2. Hypertension related to fluid volume overload

3. Deficient fluid volume related to fluid restriction

4. Personal care challenges related to fistula in left arm

5. Acute confusion related to delayed hemodialysis treatment