Nnclexs Masters



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.. Risk for impaired skin integrity related to immobility

B.. Impaired skin integrity related to immobility

C.. Constipation related to immobility

D.. 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.. Anxiety related to the hospital environment

B.. Fear related to a potentially difficult childbirth

C.. Ineffective family coping: compromised related to hospitalization

D.. 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.. Anticipatory grieving

B.. Impaired swallowing

C.. Body image disturbance

D.. 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.. Risk for infection

B.. Fluid volume excess

C.. Urinary retention

D.. 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.. Anxiety

B.. Social isolation

C.. Knowledge deficit

D.. Impaired social interaction

QUESTION 15. Which of the following is an appropriate nursing diagnosis for a patient with renal calculi?

A.. Altered tissue perfusion

B.. Functional incontinence

C.. Risk for infection

D.. 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@ 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.

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