1. Which guideline for composing a nursing diagnosis statement is correct? A. Place signs and symptoms after the etiology and link them by the phrase "as evidenced by." B. Phrase the nursing diagnosis as a client need. C. Place the etiology prior to the client problem and link it by the phrase "rel...
NUR 139 Chapter 16 Questions and
Complete Answers
1. Which guideline for composing a nursing diagnosis statement is correct?
A. Place signs and symptoms after the etiology and link them by the phrase "as
evidenced by."
B. Phrase the nursing diagnosis as a client need.
C. Place the etiology prior to the client problem and link it by the phrase "related to."
D. Incorporate subjective and judgmental terminology. ✅A
Rationale: Signs and symptoms which are defining characteristics should follow the
etiology and be linked by the phrase "as evidenced by" when included in the nursing
diagnosis. The nurse should phrase the nursing diagnosis as a client problem or
alteration in health state rather than as a client need. The client problem should precede
the etiology and be linked by the phrase "related to." The nurse should avoid using
judgmental language and write in legally advisable terms.
Question format: Multiple Choice
Chapter 16: Diagnosis/Problem Identification
Cognitive Level: Understand
Client Needs: Safe, Effective Care Environment: Management of Care
Integrated Process: Nursing Process
Reference: p. 442
2. The client is being seen for chest congestion, coughing up thick secretions, and
shortness of breath for several days and is diagnosed with pneumonia. The client has a
two-pack-per-day smoking habit. When developing the plan of care, what would be a
priority nursing diagnosis for this client?
A. Ineffective Airway Clearance related to tracheobronchial secretions as evidenced by
expectorating thick, yellow secretions
B. Ineffective Health Maintenance as evidenced by smoking and unhealthy dietary
habits
C. Ineffective Breathing Pattern related to client report of shortness of breath
D. Ineffective Therapeutic Regimen Management due to smoking ✅A
Rationale: A correctly worded problem-focused nursing statement includes three
components. The first component is the problem. The next component of the nursing
diagnosis is the etiology, which includes factors related to the problem either as causes
or contributing factors. The last component is the defining characteristics, which are
subjective and objective data that provide evidence that the client has the problem
identified. The only appropriately written nursing diagnosis among the answer options
for this question is "Ineffective Airway Clearance related to tracheobronchial secretions
as evidenced by expectorating thick, yellow secretions." The other diagnoses do not
include all three components: problem, etiology, and defining characteristics. Moreover,
,Ineffective Airway Clearance is a higher priority than Ineffective Health Maintenance,
Ineffective Breathing Pattern, or Ineffective Therapeutic Regimen Management.
Question format: Multiple Choice
Chapter 16: Diagnosis/Problem Identification
Cognitive Level: Apply
Client Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process
Reference: p. 440
3. A risk nursing diagnosis indicates that:
A. the client is more vulnerable to a certain problem than other individuals are.
B. the client is at significant risk for developing a related medical diagnosis.
C. the data necessary to make a definitive nursing diagnosis are absent.
D. the diagnosis has yet to be confirmed by another practitioner. ✅A
Rationale: Risk nursing diagnoses are clinical judgments that conclude that an
individual, family, or community is more vulnerable to develop the problem than others
in the same or similar situation. They do not denote a particular link to medical
diagnoses, nor do they lack the data necessary to make a definitive nursing diagnosis,
which is the case with possible nursing diagnoses. Risk diagnoses do not need to be
confirmed by another practitioner.
Question format: Multiple Choice
Chapter 16: Diagnosis/Problem Identification
Cognitive Level: Remember
Client Needs: Safe, Effective Care Environment: Management of Care
Integrated Process: Nursing Process
Reference: p. 440
4. A client with a new colostomy often becomes short and sarcastic when nurses
attempt to teach the client about the management of the new appliance. The nurse has
consequently documented "Noncompliance-related hostility" on the client's chart. What
mistake has the nurse made when choosing and documenting this nursing diagnosis?
A. Presuming to know the factors contributing to the problem
B. Identifying a problem that cannot be changed
C. Identifying a problem without corroborating evidence in the statement
D. Neglecting to identify potential complications related to the problem ✅A
Rationale: Multiple factors may underlie the client's response to education in a complex
and emotionally charged situation, such as receiving a new ostomy. As a result, it is
likely presumptuous to ascribe the client's response to hostility. The problem is likely
modifiable with a correct approach, the evidence underlying a nursing diagnosis is not
normally explicit in the statement itself. The existence of potential complications is not
central to the psychosocial nature of this client's situation.
Question format: Multiple Choice
Chapter 16: Diagnosis/Problem Identification
Cognitive Level: Analyze
, Client Needs: Safe, Effective Care Environment: Management of Care
Integrated Process: Nursing Process
Reference: p. 444
5. The nurse has drafted a nursing diagnosis of Imbalanced Nutrition: More Than Body
Requirements in the care of a client with a BMI of 30. How should the nurse proceed
after writing this diagnosis?
A. Validate the nursing diagnosis.
B. Identify potential complications.
C. Cross-reference the nursing diagnosis with medical diagnoses.
D. Modify interventions based on the diagnosis. ✅A
Rationale: After writing a nursing diagnosis, it is important to verify and validate it. This
action should precede the modification of the client's care. Nursing diagnoses do not
always correlate with medical diagnoses and not every nursing diagnosis is
accompanied by potential complications.
Question format: Multiple Choice
Chapter 16: Diagnosis/Problem Identification
Cognitive Level: Understand
Client Needs: Physiological Integrity: Basic Care and Comfort
Integrated Process: Nursing Process
Reference: p. 441
6. Which provides the nurse with the most reliable basis on which to formulate a nursing
diagnosis?
A. A cluster of several significant cues of data that suggest a particular health problem
B. A single, definitive cue that is closely associated with a common diagnosis
C. A cue that can be verified by objective, medical data
D. A group of related nursing diagnoses that the client already has in the same NANDA-
I-approved domain ✅A
Rationale: A data cluster is a grouping of client data or cues that points to the existence
of a client health problem. A nursing diagnosis should always be derived from a cluster
of significant data rather than from a single cue. Medical corroboration is not always
possible or necessary. A client having multiple related nursing diagnoses within one
domain does not necessarily validate another diagnosis in that same domain for the
client, nursing diagnoses are based on clusters of client data, not on other nursing
diagnoses the client may have.
Question format: Multiple Choice
Chapter 16: Diagnosis/Problem Identification
Cognitive Level: Understand
Client Needs: Safe, Effective Care Environment: Management of Care
Integrated Process: Nursing Process
Reference: p. 436
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