12: Diagnosing Chapter Review
1) A registered nurse is writing a diagnosis for a 28-
year-old male patient who is in traction due to
multiple fractures from a motor vehicle accident.
Which nursing actions are related to this step in the
nursing process? Select all that apply.
a. The nurse uses the nursing interview to collect
patient data.
b. The nurse analyzes data collected in the nursing
assessment.
c. The nurse develops a care plan for the patient.
d. The nurse points out the patient’s strengths.
e. The nurse assesses the patient’s mental status.
f. The nurse identifies community resources to
help his family cope.
2) A nurse is caring for an older adult patient who
presents with labored respirations, productive cough,
and fever. What would be appropriate nursing
diagnoses for this patient? Select all that apply.
a. Bronchial pneumonia
b. Impaired gas exchange
c. Ineffective airway clearance
d. Potential complication: sepsis
e. Infection related to pneumonia
f. Risk for septic shock
3) After assessing a patient who is recovering from a
stroke in a rehabilitation facility, a nurse interprets
and analyzes the patient data. Which of the four
basic conclusions has the nurse reached when
identifying the need to collect more data to confirm
a diagnosis of situational low self-esteem?
a. No problem
b. Possible problem
c. Actual nursing diagnosis
d. Clinical problem other than nursing diagnosis
4) A nurse assesses a patient and formulates the
following nursing diagnosis: Risk for Impaired Skin
Integrity related to prescribed bedrest as evidenced
by reddened areas of skin on the heels and back.
Which phrase represents the etiology of this
diagnostic statement?
a. Risk for Impaired Skin Integrity
b. Related to prescribed bedrest
c. As evidenced by
d. As evidenced by reddened areas of skin on the
heels and back
5) A nurse is counseling a 60-year-old female patient
who refuses to look at or care for a new colostomy.
She tells the nurse, “I don’t care what I look like
anymore, I don’t even feel like washing my hair, let
alone changing this bag.” The nurse diagnoses
Altered Health Maintenance. This is an example of
what type of problem?
a. Collaborative problem
b. Interdisciplinary problem
c. Medical problem
d. Nursing problem
6) To determine the significance of a blood pressure
reading of 148/100, it is first necessary for the nurse
to:
a. Compare this reading to standards.
b. Check the taxonomy of nursing diagnoses for a
pertinent label.
c. Check a medical text for the signs and
symptoms of high blood pressure.
d. Consult with colleagues.
7) When the initial nursing assessment revealed that a
patient had not had a bowel movement for 2 days,
the student nurse wrote the diagnostic label
“constipation.” Which of the following comments is
the nurse most likely to hear from the instructor?
a. “Hold on a minute . . . Nursing diagnoses should
always be derived from clusters of significant
data rather than from a single cue.”
b. “Job well done . . . you’ve identified this
problem early and we can manage it before it
becomes more acute.”
c. “Is this an actual or a possible diagnosis?”
d. “This is a medical, not a nursing problem.”
8) A nurse makes a clinical judgment that an African
American male patient in a stressful job is more
vulnerable to developing hypertension than White
male patients in the same or similar situation. The
nurse has formulated what type of nursing
diagnosis?
a. Actual
b. Risk
c. Possible
d. Wellness
9) A nurse is writing nursing diagnoses for patients in a
psychiatrist’s office. Which nursing diagnoses are
correctly written as two-part nursing diagnoses?
1. Ineffective Coping related to inability to
maintain marriage
2. Defensive Coping related to loss of job and
economic security
3. Altered Thought Processes related to panic
state
4. Decisional Conflict related to placement of
parent in a long-term care facility
a. (1) and (2)
b. (3) and (4)
c. (1), (2), and (3)
d. All of the above
10) A nurse writes nursing diagnoses for patients and
their families visiting a community health clinic.
Which nursing diagnoses are correctly written as
three-part nursing diagnoses?
1. Disabled Family Coping related to lack of
knowledge about home care of child on
ventilator
2. Imbalanced Nutrition: Less Than Body
Requirements related to inadequate caloric
 12: Diagnosing Chapter Review
intake while striving to excel in gymnastics
as evidenced by 20-pound weight loss since
beginning the gymnastic program, and
greatly less than ideal body weight when
compared to standard height weight charts
3. Need to learn how to care for child on
ventilator at home related to unexpected
discharge of daughter after 3-month hospital
stay as evidenced by repeated comments “I
cannot do this,” “I know I’ll harm her
because I’m not a nurse,” and “I can’t do
medical things”
4. Spiritual Distress related to inability to accept
diagnosis of terminal illness as evidenced by
multiple comments such as “How could God
do this to me?,” “I don’t deserve this,” “I
don’t understand. I’ve tried to live my life
well,” and “How could God make me suffer
this way?”
5. Caregiver Role Strain related to failure of
home health aides to appropriately diagnose
needs of family caregivers and initiate a plan
to facilitate coping as evidenced by
caregiver’s loss of weight and clinical
depression
a. (1) and (3)
b. (2) and (4)
c. (1), (2), and (3)
d. All of the above