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

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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

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

Impaired gas exchange related to alveolar-capillary membrane

d. 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.

4. The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic

statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to

ambulate. Which part of the diagnostic statement does the nurse need to revise?

a. Etiology

b. Nursing diagnosis

c. Collaborative problem

d. Defining characteristic

ANS: A

The etiology, or related to factor, of tibial fracture is a medical diagnosis and needs to be revised. The

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