This is a comprehensive and detailed practice material/testbank that contains practice questions and answers on chapter 17; Nursing Diagnosis for Nur 130.
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1. After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the
rationale for the nurse’s actions?
a. To form a language that can be encoded only by nurses
b. To distinguish the nurse’s role from the physician’s role
c. To develop clinical judgment based on other’s intuition
d. To help nurses focus on the scope of medical practice
ANS: B
The standard formal nursing diagnosis serves several purposes. Nursing diagnoses distinguish
the nurse’s role from that of the physician/health care provider and help nurses focus on the
scope of nursing practice (not medical) while fostering the development of nursing knowledge. A
nursing diagnosis provides the precise definition that gives all members of the health care team a
common language for understanding the patient’s needs. A diagnosis is a clinical judgment based
on information.
2. Which diagnosis will the nurse document in a patient’s care plan that is NANDA-I approved?
a. Sore throat
b. Acute pain
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c. Sleep apnea
d. Heart failure
ANS: B
Acute pain is the only NANDA-I approved diagnosis listed. Sleep apnea and heart failure are
medical diagnoses, and sore throat is subjective data.
3. A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of
pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the
nurse write?
a. Ineffective breathing pattern related to pneumonia
b. Risk for infection related to chest x-ray procedure
c. Risk for deficient fluid volume related to dehydration
d. Impaired gas exchange related to alveolar-capillary membrane changes
ANS: D
The related to factor of alveolar-capillary membrane changes is accurately written because it is a
patient response to the disease process of pneumonia that the nurse can treat. The related to
factor should be the cause of the problem (nursing diagnosis) that a nurse can address. The
related to factors of dehydration and pneumonia are all medical diagnoses that the nurse cannot
change. A diagnostic test or a chronic dysfunction is not an etiology or a condition that a nursing
intervention is able to treat.
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