Fundamentals of Nursing Chapter 12

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1.A

collaborative (multidisciplinary) problem is indicated instead of a

A: If both medical and nursing interventions are required to treat the problem

nursing or medical diagnosis: A: If both medical and nursing interventions are required to treat the problem B: When independent nursing actions can be utilized to treat the problem C: In cases where nursing interventions are the primary actions required to treat the problem D: When no medical diagnosis (disease) can be determined
2.An

expert nurse is able to develop a nursing diagnosis by working with

D: Analyzing data, identifying health problems, risk, and strengths, and formulating the diagnostic statements

the client. A novice nurse uses the three steps in creating a nursing diagnosis, which are: A: Medical diagnosis, interventions, evaluation B: Collecting data, analyzing data, and interpreting data C: Assessing, treating, and preventing D: Analyzing data, identifying health problems, risk, and strengths, and formulating the diagnostic statements
3.Define

"dependent functions" "independent functions"

Physician-prescribed therapies and treatments Areas of health care that are unique to nursing and separate and distinct from medical management

4.Define

5.Define

"syndome diagnosis"

A diagnosis that is associated with a cluster of other diagnoses

6.Define

"taxonomy"

A classification system or set of categories arranged based on a single principle or set of principles. In order to analyze data using a deductive approach, the nurse uses which of the following frameworks? A: Etiology B: Functional health patterns C: Risks and strengths D: Signs and symptoms B: Functional health patterns

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In the case in which a client is vulnerable to A: A risk nursing diagnosis developing a health problem, the nurse chooses which type of nursing diagnosis status? A: A risk nursing diagnosis B: A wellness nursing diagnosis C: A health promotion nursing diagnosis D: An actual nursing diagnosis In the diagnostic statement "Excess Fluid Volume related to decreased venous return as manifested by lower extremity edema (swelling)," the etiology of the problem is which of the following: A: Excess fluid volume B: Decreased venous return C: Edema D: Unknown Independent nursing interventions for a collaborative problem focus mainly on: A: Performing dependent activities B: Monitoring and preventing potential complications C: Carrying out the physician's orders D: Considering client wishes Match the definition to the type of nursing diagnosis: Based on a client's problem in the presence of sign and/or symptoms Match the definition to the type of nursing diagnosis: No problem exists but factors in the client's status leads the nurse to be concerned that a problem could occur Match the definition to the type of nursing diagnosis: Used for a healthy client who seeks to improve or maintain health Match the definition to the type of nursing diagnosis:Used Syndrome diagnosis when a diagnosis is associated with a cluster of other diagnoses Wellness diagnosis Risk nursing diagnosis Actual diagnosis B: Monitoring and preventing potential complications B: Decreased venous return

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Match the definition to the type of nursing diagnosis:Used Possible nursing diagnosis when inadequate data is available to support or refute a diagnosis Match the statement to the type of nursing diagnosis:Fear Actual diagnosis related to language barrier as manifested by apprehension, increased alertness, and increased perspiration Match the statement to the type of nursing diagnosis:Health-Seeking Behaviors related to desire to improve nutrition Match the statement to the type of nursing diagnosis:Post- Syndrome diagnosis Trauma Syndrome related to witness of a homicide as manifested by depression and substance abuse Match the statement to the type of nursing diagnosis:Risk Possible nursing diagnosis for Impaired Parenting related to unknown etiology Match the statement to the type of nursing diagnosis:Risk Risk nursing diagnosis for Perioperative Positioning Injury related to edema NANDA's official journal is now known as: International Journal of Nursing Terminologies and Classifications Nursing diagnosis differs from medical diagnosis because A: The human response to the nursing diagnosis refers to:A: The human response to medical treatmentB: Monitoring the client's conditionC: Disease processesD: Potential complications of a disease process medical treatment Wellness diagnosis

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23.One

of the primary advantages of using a three-

D: Standardizes organization of client data

part diagnostic statement such as the problemetiology-signs/symptoms (PES) format includes which of the following?A: Decreases the cost of health careB: Improves communication between nurse and clientC: Helps the nurse focus on health and wellness elementsD: Standardizes organization of client data
24.Readiness

for Enhanced Parenting is an example of D: Wellness diagnosis

a:A: Two-part diagnosisB: Health-seeking diagnosisC: Three-part diagnosisD: Wellness diagnosis

25.Taxonomy

II (NANDA International, 2005) has three B: Domains, classes, and nursing diagnoses

levels that include:A: Etiologies, complex factors, and symptomsB: Domains, classes, and nursing diagnosesC: Illness, interventions, and health promotionD: Critical thinking skills, resources, and basic nursing knowledge

26.The

advantages of using a taxonomy of nursing

A: Utilizing a single principle or set of principles Enhancing the professional nursing practice of care planningC: Maintaining currency in nursing practice because taxonomies are refined, revised, and updated as neededE: Promoting a classification system or set of categories for a single principle, or set of principles, for professional nurses

diagnoses include: (select all that apply)A: Utilizing developed by other nursing professionalsB: a single principle or set of principles developed by other nursing professionalsB: Enhancing the professional nursing practice of care planningC: Maintaining currency in nursing practice because taxonomies are refined, revised, and updated as neededD: Being used by physicians to define diagnostic nursing terminologyE: Promoting a classification system or set of categories for a single principle, or set of principles, for professional nurses
27.The

diagnostic statement most representative of a

B: Disturbed Sleep Pattern

nursing diagnosis is:A: Congestive Heart FailureB: Disturbed Sleep PatternC: PancreatitisD: Fever of Unknown Origin
28.The

first taxonomy of nursing diagnosis was

A: Alphabetically

classified:A: AlphabeticallyB: According to subject matterC: According to the International Nursing Language and ClassificationD: According to the functional health assessment
29.The

nurse describes the components of a nursing

B: Defining characteristicsC: The problem and definitionE: The etiology

diagnosis as: (select all that apply)A: Collaborative problemsB: Defining characteristicsC: The problem and definitionD: The disease processE: The etiology
30.The

nurse develops a collaborative problem such

B: Potential Complication of Immobility: Decubitus Ulcer

as:A: Risk for Decubitus Ulcer related to immobilityB: Potential Complication of Immobility: Decubitus UlcerC: Complication of Immobility: Decubitus UlcerD: Decubitus Ulcer related to immobility
31.The

nurse is conducting the diagnosing phase

B: Delineate the client's problems and strengths

(nursing diagnosis) of the nursing process for a client with a seizure disorder. Which step exists between data analysis and formulating the diagnostic statement?A: Assess the client's needsB: Delineate the client's problems and strengthsC: Determine which interventions are most likely to suceedD: Estimate the cost of several different approaches

32.The

nurse is developing a nursing diagnosis for a client

C: Identify the client's problems and

with a seizure disorder. What step does the nurse perform strengths after analyzing data?A: Estimate the cost of different approachesB: Determine which interventions are most likely to succeedC: Identify the client's problems and strengthsD: Assess the client's needs
33.The

nurse uses "secondary to" to divide what process into D: Etiology

two parts?A: Client riskB: The client's problemC: Signs and symptomsD: Etiology
34.The

nurse uses the problem, etiology, and signs and

D: Ineffective Airway Clearance related to infectious process, as manifested by excessive mucus and retained secretions

symptoms (PES) format when using the nursing diagnosis:A: Deficient Fluid Volume related to renal insufficiencyB: Ineffective Airway Clearance, as manifested by secretions in the bronchi, presence of allergies, and airway spasmC: Risk for Impaired Skin Integrity, as manifested by poor skin turgorD: Ineffective Airway Clearance related to infectious process, as manifested by excessive mucus and retained secretions
35.The

nurse, working in a clinic, admits a client for a routine D: Wellness diagnosis

annual checkup. The client identifies no current health problems. The nursing diagnosis best used for this client is a(n):A: Syndrome diagnosisB: Risk nursing diagnosisC: Actual diagnosisD: Wellness diagnosis
36.The

nurse, working in a long-term facility, is caring for an A: A possible nursing diagnosis

older adult client. The nurse notices that the client has no visitors and is pleased with attention and conversation from the nursing staff. Until more data is collected, the nurse may write:A: A possible nursing diagnosisB: A wellness nursing diagnosisC: An actual nursing diagnosisD: A syndrome nursing diagnosis
37.The

purpose of a nursing diagnosis is to:A: Establish a set C: Identify a client's problem and etiology

of principlesB: Define taxonomy of nursing languageC: Identify a client's problem and etiologyD: Promote taxonomy of nursing language
38.The

student nurse is developing a plan of care for a client. A: Analyze the dataB: Identify health problems, risk, and strengthsC: Formulate the diagnostic statement North American Nursing Diagnosis Association

In what order is the diagnostic process accomplished?A: Analyze the dataB: Identify health problems, risk, and strengthsC: Formulate the diagnostic statement
39.What

does NANDA stand for?

40.What

steps do you need to take in order to avoid errors in 1. Verify2. Build a good knowledge base and acquire clinical experience3. Have a working knowledge of what is normal4. Consult resources5. Base diagnoses on patterns that is, on behavior over time - rather than on an isolated incident6. Improve critical thinking skills

diagnostic reasoning?

41. What

type of members make up NANDA?

Staff nurses, clinical specialists, faculty, directors of nursing, deans, theorists, and researchers.

42. When

analyzing data, the nurse examines:A: Functional

A: Functional health patterns

health patternsB: Signs and symptomsC: EtiologyD: Risks and strengths

43. When

formulating nursing diagnoses, the nurse can be

B: Functional health patterns

assisted by reviewing the client's:A: Signs and symptomsB: Functional health patternsC: EtiologyD: Risks and strengths
44. When

writing a basic two-part diagnostic statement, the

B: Problem and etiology

nurse includes:A: Signs, symptoms, and etiologyB: Problem and etiologyC: "Related to" and etiologyD: "Manifested by" and etiology
45. When

writing a nursing diagnosis, the nurse needs to be

B: A need

able to distinguish a problem from:A: A causeB: A needC: The signs and symptomsD: The risks
46. When

writing a nursing diagnosis, the nurse uses:A:

B: Nursing terminology

Layman's termsB: Nursing terminologyC: Medical terminologyD: Medical diagnoses

47. When

writing a quality nursing diagnostic statement, it is A: Use nonjudgmental statementsC: Be sure that cause and effect are correctly stated (i.e., the etioloogy causes the problem or puts the client at risk for the problem)D: Word the diagnosis specifically and prescisely to provide direction for planning nursing

important for the nurse to:A: Use nonjudgmental statementsB: Use medical terminology to describe the probably cause of the client's responseC: Be sure that cause and effect are correctly stated (i.e., the etioloogy causes the problem or puts the client at risk for the to provide direction for planning nursing interventionsE: State in terms of a need, not a problem
48. Which

problem)D: Word the diagnosis specifically and prescisely interventions

of the following is true regarding the state of the

C: More research is needed to validate and refine the diagnostic labels

science in regards to nursing diagnosis?A: The original taxonomy has proven to be adequate in scopeB: The organizing framework of the taxonomy is based on the work of Florence NightingaleC: More research is needed to validate and refine the diagnostic labelsD: New diagnostic labels are approved by means of a vote of registered nurses

49. Which

of the following nursing diagnoses contains the

A: Risk for Caregiver Role Strain related to unpredictable illness course

proper components?A: Risk for Caregiver Role Strain related to unpredictable illness courseB: Risk for Falls related to tendency to collapse when having difficulty breathingC: Impaired Communication related to strokeD: Sleep Deprivation secondary to fatigue and a noisy environment
50.Which

of the following would indicate a significant cue when A: The client has moved partway toward a set goal (e.g., weight loss)D: A woman widowed recently states she is "unable to cry."E: A 16-year-old high school student reports spending 6 hours doing

comparing data to standards? (select all that apply)A: The client has moved partway toward a set goal (e.g., weight loss)B: The client's vision is within normal range only when wearing glassesC: A child is able to control bladder and she is "unable to cry."E: A 16-year-old high school student reports spending 6 hours doing homework five nights per week.

bowels at age 18 monthsD: A woman widowed recently states homework five nights per week.