Nclex Masters.
Nursing Intervention. Diagnosis or Analysis
Diagnostic Exam Number 1. Question Answers and Clinical Reasoning
QUESTION 1. While caring for a patient who is immobile, the nurse
documents the following information on the patient's chart : "Turned
patient from side to back every 2 hours." "Skin intact; no redness
noteD.." "Patient up in chair three times today." "Improved skin turgor
noteD.." Which nursing diagnosis accurately reflects this information?
A..
B..
C..
D..
Risk for impaired skin integrity related to immobility
Impaired skin integrity related to immobility
Constipation related to immobility
Body image disturbance related to immobility
QUESTION 2. The nurse is developing a list of nursing diagnoses for a
patient. This list should include:
A.. actions to achieve goals
B.. expected outcomes
C.. factors influencing the patient's problem
D.. nursing history
QUESTION 3. Which of the following is an approved nursing diagnosis?
A.. "Administer a sedative at bedtime"
B.. "Pupils round, reactive to light and accommodation"
C.. "Patient will demonstrate subcutaneous injection independently"
D.. "Impaired gas exchange related to atelectasis"
QUESTION 4. Which is the most appropriate nursing diagnosis for a
preschool child with epiglottitis?
A.. Anxiety related to separation from parent
B.. Decreased cardiac output related to bradycardia
C.. Ineffective airway clearance related laryngospasm
D.. Impaired gas exchange related to noncompliant lungs
QUESTION 5. The nurse formulates a nursing diagnosis of "high risk for
infection" for a child with Down syndrome. Which condition typically
seen in children with this syndrome supports this nursing diagnosis?
A.. Muscular hypotonicity
B.. Muscle spasticity
C.. Increased mucus viscosity
D.. Hypothyroidism.
QUESTION 6. A girl, age 13, with anorexia nervosa is admitted to the
hospital for I.V. fluid therapy and nutritional management. She says
she is worried that the I.V. fluids will make her gain weight. Which
nursing diagnosis is most appropriate?
A.. Noncompliance
B.. Body image disturbance
C.. Dysfunctional grieving
D.. Anticipatory grieving
QUESTION 7. At the health clinic, a sexually active girl, age 15, tells
the nurse she is worried that her parents may find out about her sexual
activity. "They would never approve," she says. The nurse should
formulate which nursing diagnosis?
A.. Altered growth and development patterns related to sexual activity
B.. Impaired social interaction patterns related to boyfriend's
expectations
C.. Altered sexuality patterns related to parent's expectations
D.. Fear related to boyfriend's expectations
QUESTION 8. A patient is brought to the hospital in an agitated state
and is admitted to the psychiatric unit for observation and treatment.
While putting personal items away, the patient talks rapidly and folds
and unfolds garments several times. The patient cannot seem to settle
down. Which nursing diagnosis is most applicable at this time?
A.. Self-care deficit
B.. Anxiety
C.. Impaired verbal communication
D.. Powerlessness
QUESTION 9. A patient with borderline personality disorder is admitted
to the psychiatric unit. Initial nurisng assessment reveals that the
patient's wrists are scratched from a recent suicide attempt. Based on
this finding, the nurse should formulate a nursing diagnosis of:
A.. ineffective individual coping related to feelings of guilt
B.. self-esteem disturbance related to feelings of loss of control
C.. risk for violence: self-directed related to impulsive mutilating
acts
D.. risk for violence: directed toward others related to verbal
threats
QUESTION 10.
The nurse notices that a patient in the first stage
of labor seems agitateD.. When the nurse asks why she is upset, she
begins to cry and says, "I guess I'm a little worrieD.. The last time I
gave birth, I was in labor for 32 hours." Based on this information,
the nurse should include which nursing diagnosis in the patient's plan
of care?
A..
B..
C..
D..
Anxiety related to the hospital environment
Fear related to a potentially difficult childbirth
Ineffective family coping: compromised related to hospitalization
Pain related to labor contractions
QUESTION 11.
A patient complains of sporadic epigastric pain,
yellowish skin discoloration, nausea, vomiting, weight loss, and
fatigue. Suspecting gallbladder disease, the doctor orders a diagnostic
workup, which reveals gallbladder cancer. Which nursing diagnosis may
be appropriate for this patient?
A..
B..
C..
D..
Anticipatory grieving
Impaired swallowing
Body image disturbance
Chronic low self-esteem
QUESTION 12.
A patient is transferred to a rehabilitation center
after being treated in the hospital for a cerebrovascular accident
(CVA). Because the patient has a history of Cushing's syndrome
(hypercortisolism) and chronic obstructive pulmonary disease, the nurse
formulates a nursing diagnosis of:
A.. risk for fluid volume deficit related to excessive sodium loss
B.. risk for impaired skin integrity related to tissue catabolism
secondary to cortisol hypersecretion
C.. altered health maintenance related to frequent hypoglycemic
episodes secondary to Cushing's syndrome
D.. decreased cardiac output related to hypotension secondary to
Cushing's syndrome
QUESTION 13..
Which nursing diagnosis is most appropriate for a
patient with Addison's disease?
A..
B..
C..
D..
Risk for infection
Fluid volume excess
Urinary retention
Hypothermia
QUESTION 14.
An elderly female patient is diagnosed with pulmonary
tuberculosis. Upset and tearful, she asks the nurse how long she must
be separated from her family. Which nursing diagnosis is most
appropriate for this patient?
A..
B..
C..
D..
Anxiety
Social isolation
Knowledge deficit
Impaired social interaction
QUESTION 15.
Which of the following is an appropriate nursing
diagnosis for a patient with renal calculi?
A..
B..
C..
D..
Altered tissue perfusion
Functional incontinence
Risk for infection
Decreased cardiac output.
This is the end of Diagnoses exam number one. The answers, and clinical
reasoning follows on the next audio file.
Print the Answers and clinical reasoning file before attempting to
answer any questions.
Remember to translate and submitt to RNeducator@Nclexmasters.com a
literal translation within 5 days from downloading of this pracitce
exam.
Nclexs Masters questions, answers and clinical reasons.
Diagnosis Exam Number One. Answers to questions 1 through 15.
Question one.
1.
While caring for a patient who is immobile, the nurse documents
the following information in the patient's chart: "Turned patient from
side to back every 2 hours." "Skin intact; no redness noted." "Patient
up in chair three times today." "Improved skin turgor noted." Which
nursing diagnosis accurately reflects this information?
The right answer is: A. Risk for impaired skin integrity related to
immobility
CLINICAL REASONING: The information documented in the patient's chart
reflects the potential for impaired skin integrity. Because the
patient's skin is intact, the problem is only a potential one, not an
actual one, making the nursing diagnosis of "impaired skin integrity"
inappropriate. If constipation were a problem, interventions would
focus on diet and activity. If "body image disturbance" were a problem,
interventions would focus on the patient's feelings about self and the
disease.
NURSING PROCESS: Nursing diagnosis
PATIENTS NEEDS:: Physiological integrity
TAXONOMY: Comprehension
2.
The nurse is developing a list of nursing diagnoses for a
patient. This list should include:
The right answer is: C. factors influencing the patient's problem.
CLINICAL REASONING: A nursing diagnosis is a written statement of the
patient's actual or potential health problem. It includes a specified
diagnostic label, factors that influence the patient's problem, and any
signs or symptoms that help define the diagnostic label. Actions to
achieve goals are nursing interventions. Expected outcomes are
measurable behavioral goals that the nurse develops during the
evaluation step of the nursing process. The nurse obtains a nursing
history during the assessment step of the nursing process.
NURSING PROCESS: Nursing diagnosis
PATIENTS NEEDS:: Safe, effective care environment
TAXONOMY: Synthesis.
3.
Which of the following is an approved nursing diagnosis?
The right answer is: D. "Impaired gas exchange related to atelectasis"
CLINICAL REASONING: Impaired gas exchange related to atelectasis is an
approved nursing diagnosis--a statement about the patient's health
problem. Option A is a nursing order; Option B, an assessment finding;
and Option C, a patient outcome statement.
NURSING PROCESS: Nursing diagnosis
PATIENTS NEEDS:: Physiological integrity
TAXONOMY: Comprehension.
4.
Which is the most appropriate nursing diagnosis for a preschool
child with epiglottitis?
The right answer is: C. Ineffective airway clearance related
laryngospasm.
CLINICAL REASONING: Epiglottitis is an immediate threat to life because
complete upper airway obstruction may occur suddenly and be
precipitated by improper examination or intervention. The upper airway
obstruction is the result of laryngospasm and edema. The patient is
anxious because of respiratory distress. The nurse should allow the
parent to stay with the child and should encourage the parent to hold
and reassure the child. The child has impaired gas exchange from
impeded airflow, not from a noncompliant lung. The child will probably
be tachycardic until respiratory failure ensues.
NURSING PROCESS: Nursing diagnosis
PATIENTS NEEDS : Physiological integrity
TAXONOMY: Application.
5.
The nurse formulates a nursing diagnosis of "high risk for
infection" for a child with Down syndrome. Which condition typically
seen in children with this syndrome supports this nursing diagnosis?
The right answer is: A. Muscular hypotonicity.
CLINICAL REASONING: Several conditions make the child with Down
syndrome highly vulnerable to respiratory infections. For example, the
hypotonicity of chest muscles leads to diminished respiratory expansion
and pooling of secretions, while an underdeveloped nasal bone impairs
mucus drainage. Down syndrome is not associated with muscle spasticity
or increased mucus viscosity. Although hypothyroidism is common in
children with Down syndrome, it does not increase the risk of
infection.
NURSING PROCESS: Nursing diagnosis.
PATIENTS NEEDS:: Health promotion and maintenance.
TAXONOMY: Knowledge.
6.
A girl, age 13, with anorexia nervosa is admitted to the hospital
for I.V. fluid therapy and nutritional management. She says she is
worried that the I.V. fluids will make her gain weight. Which nursing
diagnosis is most appropriate?
The right answer is: B. Body image disturbance
CLINICAL REASONING: The patient with anorexia nervosa has a "body image
disturbance," viewing herself as fat despite physical evidence to the
contrary. One goal of nursing care is to help her develop realistic
perceptions about her body. Although the patient has expressed concern
about weight gain from I.V. fluids, no information suggests she will
refuse the treatment; therefore, a nursing diagnosis of "noncompliance"
is not warranted. Likewise, no evidence supports the nursing diagnoses
of "dysfunctional grieving or anticipatory grieving."
NURSING PROCESS: Nursing diagnosis
PATIENTS NEEDS:: Psychosocial integrity
TAXONOMY: Evaluation.
7.
At the health clinic, a sexually active girl, age 15, tells the
nurse she is worried that her parents may find out about her sexual
activity. "They would never approve," she says. The nurse should
formulate which nursing diagnosis?
The right answer is: C. Altered sexuality patterns related to parent's
expectations.
CLINICAL REASONING: This child is expressing concerns about the
conflict between her parent's expectations and her own desires. Sexual
activity is a normal experimental pattern for many adolescents, but
this patient verbalizes parental expectations against this behavior. No
evidence suggests she is having a conflict with her boyfriend or
problems with social interactions.
NURSING PROCESS: Nursing diagnosis
PATIENTS NEEDS:: Psychosocial integrity
TAXONOMY: Analysis.
8.
A patient is brought to the hospital in an agitated state and is
admitted to the psychiatric unit for observation and treatment. While
putting personal items away, the patient talks rapidly and folds and
unfolds garments several times. The patient cannot seem to settle down.
Which nursing diagnosis is most applicable at this time?
The right answer is: B. Anxiety
CLINICAL REASONING: Anxiety is the most applicable nursing diagnosis at
this time because the patient's behavior mimics some of the objective
signs of anxiety, which include restlessness, irritability, rapid
speech, inability to complete tasks, and verbal expressions of tension.
The other options would be premature because the nurse has not had an
opportunity to complete a thorough nursing assessment.
NURSING PROCESS: Nursing diagnosis
PATIENTS NEEDS:: Psychosocial integrity
TAXONOMY: Evaluation.
9.
A patient with borderline personality disorder is admitted to the
psychiatric unit. Initial nurisng assessment reveals that the patient's
wrists are scratched from a recent suicide attempt. Based on this
finding, the nurse should formulate a nursing diagnosis of:
The right answer is: C. risk for violence: self-directed related to
impulsive mutilating acts.
CLINICAL REASONING: The predominant behavioral characteristic of the
patient with borderline personality disorder is impulsiveness,
especially of a physically self-destructive sort. The observation that
the patient has scratched wrists does not substantiate the other
options.
NURSING PROCESS: Nursing diagnosis
PATIENTS NEEDS:: Physiological integrity
TAXONOMY: Knowledge.
10.
The nurse notices that a patient in the first stage of labor
seems agitated. When the nurse asks why she is upset, she begins to cry
and says, "I guess I'm a little worried. The last time I gave birth, I
was in labor for 32 hours." Based on this information, the nurse should
include which nursing diagnosis in the patient's plan of care?
The right answer is: B. Fear related to a potentially difficult
childbirth
CLINICAL REASONING: A patient's ability to cope during labor and
delivery may be hampered by fear of a painful or difficult childbirth,
fear of loss of control or self-esteem during childbirth, or fear of
fetal death. A previous negative experience may increase these fears.
Therefore, "fear related to a potentially difficult childbirth" is the
most appropriate nursing diagnosis. The patient's anxiety stems from
her past history of a long labor, not from being in the hospital;
therefore, "anxiety related to the hospital environment" is not
warranted. There is no evidence of "ineffective family coping:
compromised related to hospitalization." Although "pain related to
labor contractions" may be a problem, this is not mentioned in the
question.
NURSING PROCESS: Nursing diagnosis
PATIENTS NEEDS:: Psychosocial integrity
TAXONOMY: Synthesis.
11.
A patient complains of sporadic epigastric pain, yellowish skin
discoloration, nausea, vomiting, weight loss, and fatigue. Suspecting
gallbladder disease, the doctor orders a diagnostic workup, which
reveals gallbladder cancer. Which nursing diagnosis may be appropriate
for this patient?
The right answer is: A. Anticipatory grieving.
CLINICAL REASONING: "Anticipatory grieving" is an appropriate nursing
diagnosis for this patient because few patients with gallbladder
disease live more than 1 year after diagnosis. "Impaired swallowing" is
not associated with gallbladder cancer. Although surgery typically is
done to remove the gallbladder and possibly a section of the liver, it
is not disfiguring and does not cause a "body image disturbance."
"Chronic low self-esteem" is not an appropriate nursing diagnosis at
this time because the diagnosis has just been made.
NURSING PROCESS: Nursing diagnosis
PATIENTS NEEDS:: Psychosocial integrity
TAXONOMY: Analysis.
12.
A patient is transferred to a rehabilitation center after being
treated in the hospital for a cerebrovascular accident (CVA). Because
the patient has a history of Cushing's syndrome (hypercortisolism) and
chronic obstructive pulmonary disease, the nurse formulates a nursing
diagnosis of:
The right answer is: B. risk for impaired skin integrity related to
tissue catabolism secondary to cortisol hypersecretion
CLINICAL REASONING: Cushing's syndrome causes tissue catabolism,
resulting in thinning skin and connective tissue loss; along with
immobility related to CVA, these factors increase this patient's "risk
for impaired skin integrity." The exaggerated glucocorticoid activity
in Cushing's syndrome causes sodium and water retention, in turn
leading to edema and hypertension. Therefore, "risk for fluid volume
deficit" and "decreased cardiac output" are inappropriate nursing
diagnoses. Increased glucocorticoid activity also causes persistent
hyperglycemia, eliminating "altered health maintenance related to
frequent hypoglycemic episodes."
NURSING PROCESS: Nursing diagnosis
PATIENTS NEEDS:: Health promotion and maintenance
TAXONOMY: Analysis.
13.
Which nursing diagnosis is most appropriate for a patient with
Addison's disease?
The right answer is: A. Risk for infection.
CLINICAL REASONING: Addison's disease decreases the production of all
adrenal hormones, compromising the body's normal stress response and
increasing the risk of infection. Other appropriate nursing diagnoses
for a patient with Addison's disease include "fluid volume deficit" and
"hyperthermia." "Urinary retention" is not appropriate because
Addison's disease causes polyuria.
NURSING PROCESS: Nursing diagnosis
PATIENTS NEEDS:: Physiological integrity
TAXONOMY: Evaluation.
14.
An elderly female patient is diagnosed with pulmonary
tuberculosis. Upset and tearful, she asks the nurse how long she must
be separated from her family. Which nursing diagnosis is most
appropriate for this patient?
The right answer is: C. Knowledge deficit.
CLINICAL REASONING: This patient is exhibiting a "knowledge deficit"
because treatment of tuberculosis no longer requires isolation,
provided the patient complies with the prescribed medication regimen.
Although the patient is upset, her question reflects sadness at the
prospect of being separated from her family, rather than "anxiety"
about the disease. Because she has just been diagnosed and has not had
a chance to demonstrate compliance, a nursing diagnosis of "social
isolation" is not appropriate. "Impaired social interaction" usually
has a psychiatric or neurologic basis, not a respiratory one, such as
pulmonary tuberculosis.
NURSING PROCESS: Nursing diagnosis
PATIENTS NEEDS:: Health promotion and maintenance
TAXONOMY: Analysis.
15.
Which of the following is an appropriate nursing diagnosis for a
patient with renal calculi?
The right answer is: C. Risk for infection.
CLINICAL REASONING: Infection can occur with renal calculi from urine
stasis caused by obstruction. Options A and D are not appropriate for
this diagnosis, and retention of urine usually occurs rather than
incontinence.
NURSING PROCESS: Nursing diagnosis
PATIENTS NEEDS:: Physiological integrity
TAXONOMY: Application.
This is the end of the Questions, answers and clinical reasoning audio
file. A reason justifying the answer was given for each question. Take
note of each reason given.