Online Practice Test 12

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Site Title: Kozier & Erb's Fundamentals of Nursing Book Title: Kozier & Erb's Fundamentals of Nursing Location on Site: Chapter 12 > NCLEX® Review Date/Time Submitted: July 7, 2012 at 2:38 PM (UTC/GMT)

Summary of Results 60% Correct of 10 Scored items: 6 Correct:  60% 4 Incorrect:  40% More information about scoring

1.		Consider the following nursing diagnosis: Ineffective Breathing Pattern related to respiratory muscle fatigue as evidenced by use of accessory muscles. Which part represents the etiology for this diagnosis? Your Answer: Respiratory muscle fatigue
		Objective: Identify the components of a nursing diagnosis. Rationale: The etiology component identifies one or more probable causes of the health problem.Respiratory muscle fatigue is a probable cause of the diagnosis. Ineffective breathing pattern is not a diagnostic label. Related to represents that this is a relationship. Use of accessory muscles is a defining characteristic. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
2.		Consider the following nursing diagnosis: Chronic Pain related to pain from stiff joints. What is the error in this diagnosis?  Your Answer: It says the same thing twice.
		Objective: List common errors in writing diagnostic statements. Rationale: A properly written nursing diagnosis needs to have each component stated correctly. The etiology must not restate the diagnostic label. Answer 1 is not a wellness or syndrome diagnosis. In Answer 2, there is no medical diagnosis in the nursing diagnosis. This is a nonjudgmental statement. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection
3.		Which of the following wellness diagnoses is written correctly? Your Answer: Readiness for Enhanced Health-Seeking Behavior R/T making a clinic visit Correct Answer: Readiness for Enhanced Health-Seeking Behaviors (low-sodium diet)
		Objective: List common errors in writing diagnostic statements. Rationale: NANDA has specified that wellness diagnoses will be one-part statements that begin with "Readiness for Enhanced". There is no related factor in wellness diagnosis. Answer 3 does not include "enhanced", so it is not a proper wellness diagnosis. Answer 4 does not include "Readiness for", so it is not proper wellness diagnosis. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
4.		Which of the following is a correctly written nursing diagnosis that the nurse should add to the client's care plan? Your Answer: Altered Nutrition: Less than Body Requirements Correct Answer: Impaired Physical Mobility related to weakness in lower extremities
		Objective: List common errors in writing diagnostic statements. Rationale: A two-part nursing diagnosis requires the diagnostic label (problem statement) and etiology (probable cause). Answer 1 is a diagnostic label only, and does not include etiology. Answer 2 is a medical diagnosis, not a nursing diagnosis. Answer 4 restates the diagnosis. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
5.		What would the nurse need to do to make the following diagnosis more complete: Ineffective Individual Coping related to a situational crisis (recent diagnosis of a terminal illness). Your Answer: Expand the etiology to include the specific condition Correct Answer: Add defining characteristics, verbal and nonverbal
		Objective: List common errors in writing diagnostic statements. Rationale: A three-part statement requires a diagnostic label, etiology, and defining charactistics (signs and symptoms). The etiology is correctly stated as is. The diagnostic label is correctly stated as is. Individual Coping is an appropriate nursing diagnosis. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
6.		When evaluating a child's ability to use language, the nurse considers the child's age. This is an example of: Your Answer: Comparing data against standards
		Objective: Describe various formats for writing nursing diagnoses. Rationale: Nurses must compare data to standards and norms to identify significant and relevant cues. Clustering data is incorrect because the nurse who clusters data has subjective and objective data that are grouped in a meaningful manner. The nurse has only one piece of information, and does not need to differentiate it from other data. Determining inconsistencies in the data is incorrect because there are no inconsistencies when having a blood pressure reading. The nurse must compare it to norms or standards. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection
7.		Which of the following is stated in the format of a collaborative problem? Your Answer: Complication of Immobility: Decubitus Ulcer Correct Answer: Potential Complication of Immobility: Decubitus Ulcer
		Objective: Describe various formats for writing nursing diagnoses. Rationale: Collaborative problems are potential problems that nurses manage using both independent and physician-prescribed interventions. A risk diagnosis is not a collaborative problem. Decubitus ulcer related to immobility is not stated in the form of a nursing diagnosis. Complication of Immobility: Decubitus Ulcer is not stated in the form of a nursing diagnosis. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
8.		Which of the following nursing diagnoses uses the PES format? Your Answer: Ineffective Airway Clearance related to infectious process as manifested by excessive mucous and retained secretions
		Objective: List advantages of a taxonomy of nursing diagnoses. Rationale: The basic three-part statement has a problem (P), etiology (E), and signs and symptoms (S). Fluid Volume Deficit related to prolonged vomiting is an incorrect diagnosis because no signs or symptoms are present. Risk for Impaired Skin Integrity as manifested by poor skin turgor and old age is an incorrect diagnosis because there is no etiology stated. Ineffective Airway Clearance as manifested by secretions in the bronchi, presence of allergies, and airway spasm is an incorrect diagnosis because there is no etiology stated. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
9.		An adolescent withholds information out of embarrassment and a need for privacy. If the nurse makes a diagnostic error, it would be due to: Your Answer: Incomplete data
		Objective: List common errors in writing diagnostic statements. Rationale: Nurses can avoid errors in diagnostic reasoning by verifying data insofar as possible, having a strong knowledge base, understanding what is normal, consulting appropriate resources, and improving critical thinking skills. Lack of experience in this case is not a likely cause of failure to properly diagnose an adolescent. The age of the nurse should not have an effect on diagnostic reasoning. The nurse needs to verify data prior to making a diagnosis, and should not make inferences from prior experiences. Prior experience should lead to an understanding that additional data are required. Nursing Process: Assessment Client Need: Psychological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
10.		Which of the following diagnoses identifies the individual or aggregate condition or state that may be improved by health-promoting activities? Your Answer: Readiness for Enhanced Family Coping related to the birth of a new baby as manifested by many questions about infant care
		Objective: Describe the evolution of the nursing diagnosis movement, including work currently in progress. Rationale: There are five types of nursing diagnoses. An actual diagnosis is based on the presence of signs and symptoms. A risk nursing diagnosis is based on the nurse's judgment that a problem may develop if the nurse does not intervene. A wellness diagnosis is based on the judgment that an individual, family, or aggregate is in transition to a higher level of wellness. A possible nursing diagnosis is one in which evidence about a health problem is unclear. A syndrome diagnosis is one that is associated with a cluster of other diagnoses. Answer 2 is an actual nursing diagnosis unrelated to wellness. Answer 3 does not consider wellness factors. Answer 4 does not consider wellness factors. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.