12 Nursing Diagnosis NCLEX Practice Questions

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• 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.

• The nurse analyzes data collected in the nursing

assessment.

• The nurse develops a care plan for the patient.
• The nurse points out the patient's strengths.
• The nurse assesses the patient's mental status.
• The nurse identifies community resources to help his

family cope.

• The nurse analyzes data collected in the nursing assessment.
• The nurse points out the patient's strengths.
• The nurse identifies community resources to help his family cope.

• 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.

• Bronchial pneumonia
• Impaired gas exchange
• Ineffective airway clearance

d. Potential complication: sepsis

• Infection related to pneumonia
• Risk for septic shock
• Impaired gas exchange
• Ineffective airway clearance
• Risk for septic shock
• 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?

• No problem
• Possible problem
• Actual nursing diagnosis
• Clinical problem other than nursing diagnosis
• Possible problem
• 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?

• Risk for Impaired Skin Integrity
• Related to prescribed bedrest
• As evidenced by

d.As evidenced by reddened areas of skin on the heels and back

• Related to prescribed bedrest

• 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?

• Collaborative problem
• Interdisciplinary problem
• Medical problem
• Nursing problem
• Nursing problem
• To determine the significance of a blood pressure

reading of 148/100, it is first necessary for the nurse to:

• Compare this reading to standards.
• Check the taxonomy of nursing diagnoses for a

pertinent label.

• Check a medical text for the signs and symptoms of

high blood pressure.

• Consult with colleagues.
• Compare this reading to standards.
• 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?

• "Hold on a minute . . . Nursing diagnoses should always

be derived from clusters of significant data rather than from a single cue."

• "Job well done . . . you've identified this problem early

and we can manage it before it becomes more acute."

• "Is this an actual or a possible diagnosis?"
• "This is a medical, not a nursing problem."
• "Hold on a minute . . . Nursing diagnoses should always be derived from

clusters of significant data rather than from a single cue."

• 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?

• Actual
• Risk
• Possible
• Wellness
• Risk
• 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

• (1) and (2)
• (3) and (4)
• (1), (2), and (3)
• All of the above
• All of the above