Ch 12: Diagnosing PrepU

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An example of a nursing diagnosis from the Perception/Cognition domain is: a) Readiness for Enhanced Sleep. b) Impaired Verbal Communication. c) Impaired Social Interaction. d) Health-Seeking Behaviors.

An experienced obstetrical nurse is collecting data on a patient in labor. What is the best approach for the development of nursing diagnoses for this patient? a) Develop each nursing diagnoses based upon a single cue. b) Develop nursing diagnoses from clusters of significant data. c) Collaborate with the multiple disciplinary team in the formation of nursing diagnoses. d) Collaborate with the physician in the formation of nursing diagnoses.

The care plan for a client who has been frequently admitted to the hospital for exacerbation of COPD (chronic obstructive pulmonary disease) has a nursing diagnosis of "Noncompliance related to lack of knowledge as evidenced by frequent admissions to the hospital." What is the most appropriate method for the nurse to use to validate the nursing diagnosis?

Assess the client's knowledge of COPD.

self actualization

Because basic needs must be met before a person can focus on higher ones, patient needs may be prioritized according to the following hierarchy from Maslow: physiologic needs, safety needs, love and belonging needs, self esteem needs, _______ needs.

A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination?

Bowel Incontinence

A nurse is interviewing an asthmatic client who has a high respiratory rate and is having difficulty breathing. What appropriate nursing diagnosis should the nurse document? a) Impaired gas exchange related to the disease condition b) Impaired verbal communication related to the breathing problem c) Inability to speak due to ineffective airway clearance d) Impaired physical mobility related to tachypnea

A nurse is reviewing the plan of care for a client with a breathing problem. Which of the following would the nurse most likely expect to identify as a relevant nursing diagnostic statement for this client? a) Altered airway b) Impaired respiration c) Impaired breathing rate d) Ineffective airway clearance

A nurse who is caring for a client admitted to the nursing unit with acute abdominal pain formulates the care plan for the client. Which of the following nursing diagnoses is the highest priority for this client? a) Disturbed sleep pattern b) Disturbed body image c) Activity intolerance d) Impaired comfort

A pregnant client asks the nurse for information on breastfeeding her baby. What type of nursing diagnosis would the nurse formulate?

A wellness diagnosis

A nurse is applying the nursing process and is in the diagnosis phase. With which activities would the nurse be involved? Select all that apply.

• Analyzing data • Identifying patterns • Identifying indicators of potential dysfunction

The nurse is providing care for a client who experienced an ischemic stroke 5 days ago. The client now has difficulty swallowing liquids solids, weakness on the right side of the body and incontinent of bowel and bladder. Which priority nursing diagnoses would the nurse identify and document in the care of this client? Select all that apply.

• Bowel Incontinence • Impaired Swallowing • Impaired Physical Mobility

A nursing diagnosis of "Complicated Grieving" has been identified for a client whose spouse died 1 year ago. What assessment data would be appropriate evidence to justify this diagnosis? Select all that apply.

• The client no longer indulges in his usual activities. • The client attempted suicide 1 month ago. • The client states, "I have no interest in doing anything."

A nursing diagnosis of "Ineffective Coping" has been chosen for a client after receiving a diagnosis of prostate cancer. What assessments would the nurse consider as evidence for this diagnosis? Select all that apply.

• The client reports an inability to get adequate restful sleep. • The client has difficulty concentrating on the details of treatment options. • The client states, "I can't handle all of this."

After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type?

Actual

Which of the following is classified as a nursing diagnosis?

Grieving

actual

After assessing a client, the nurse formulates several nursing diagnoses. Which of the following would the nurse identify as an actual nursing diagnosis? a) Possible impaired adjustment b) Readiness for enhanced sleep c) Risk for infection d) Impaired urinary elimination

After educating a group of students on the different types of nursing diagnoses, the instructor determines that the education was successful when the students identify wellness diagnoses statements as consisting of how many parts? a) 4 b) 1 c) 2 d) 3

What does the nursing diagnosis represent?

Cues

While developing a plan of care for a client, what should the nurse do before selecting a nursing diagnosis?

Collect client subjective and objective data.

A client reports not having a bowel movement for 7 days, followed by a day of small, loose stools. How does the nurse define the health problem?

Constipation related to irregular evacuation patterns

A nurse in the emergency room, who is unfamiliar with pediatric clients, assesses the vital signs of a 1-month old infant with a heart rate of 124 and a respiratory rate of 36. What would be the most appropriate measure for the nurse to take to analyze the significance of the infant's vital signs?

Consult reference materials to determine the normal vital signs for 1-month old infants.

Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis

A nurse is developing the plan of care for a client and establishes several nursing diagnoses based on assessment data. The nurse demonstrates an understanding of nursing diagnoses by focusing on which area?

Human responses to actual or potential health problems

In the development of a nursing diagnosis for a client who has cachexia and decreased weight, what would be an appropriate nursing diagnosis?

Imbalanced nutrition: less than body requirements

A nurse is interviewing an asthmatic client who has a high respiratory rate and is having difficulty breathing. The client is consequently restless and can only speak a few words before pausing to catch her breath. What appropriate nursing diagnosis should the nurse document?

Impaired Verbal Communication related to the breathing problem

Impaired physical mobility related to pain

A client is brought to the emergency room in respiratory arrest and immediately intubated and placed on mechanical ventilation. What is the most appropriate nursing diagnosis for this client?

Impaired spontaneous ventilation

In planning the care for a client who has pneumonia, the nurse collects data and develops nursing diagnoses. Which of the following is an example of a properly developed nursing diagnosis? a) Ineffective health maintenance as evidenced by unhealthy habits b) Ineffective airway clearance as evidenced by inability to clear secretions c) Ineffective therapeutic regimen management due to smoking d) Ineffective breathing pattern related to pneumonia

In the development of a nursing diagnosis for a client who has cachexia and decreased weight, what would be an appropriate nursing diagnosis? a) Anorexia nervosa and bulimia b) Imbalanced nutrition: less than body requirements c) Weight loss related to abdominal discomfort d) Lack of adequate nutrition related to decreased calories

A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis?

Ineffective Airway Clearance

Ineffective Health Maintenance related to client's denial of illness

A community group has requested the public health nurse to present a program describing the advised schedule of immunizations for children. To plan for this program, what nursing diagnosis would be most appropriate for the nurse to select?

Readiness for enhanced knowledge: childhood immunizations

An older adult client recently admitted to a long term care facility expresses anger and depression about the relocation. The client consumes very little food and is losing weight. What nursing diagnosis would be most appropriate for the nurse to select in order to plan this client's care?

Relocation Stress Syndrome

Risk for Allergy Response related to latex allergy

Which is an accurately phrased risk diagnosis?

Risk for Falls related to altered mobility.

Which statement appropriately identifies an at-risk nursing diagnosis for a woman 78 years of age who is confined to bed?

Risk for impaired skin integrity related to bed rest

A, B, E

Select all answer choices that apply. The nurse is providing care for a client who experienced an ischemic stroke five days ago. Which of the following diagnoses would the nurse be justified in identifying and documenting in the care of this client? Select all that apply. a) Bowel Incontinence b) Impaired Physical Mobility c) Risk for Hemiparesis d) Dysphagia e) Impaired Swallowing

A, C, D

Select all answer choices that apply. Which activities does the nurse perform during the diagnosing stage? Select all that apply. a) Identifies factors contributing to the client's health problem. b) Collects data to monitor quality and effectiveness of nursing practice. c) Validates the identified health problems with the clients. d) Prioritizes the client's health problems with input from the client. e) Establishes plan priorities with the client and family.

The nurse is caring for a client who underwent surgery 1 day ago. Which client problem can be addressed by independent nursing diagnoses?

The client has diminished breath sounds.

The nurse has drafted a nursing diagnosis of Imbalanced Nutrition: More Than Body Requirements in the care of moderately obese client. How should the nurse proceed after writing this diagnosis? a) Modify interventions based on the diagnosis b) Cross-reference the nursing diagnosis with medical diagnoses c) Identify potential complications d) Validate the nursing diagnosis

The nurse formulates the nursing diagnosis: Disturbed Body Image related to decreased ability to cope with surgical removal of right breast AEB client refuses to look at surgical site and client statement, "I'm ugly. My husband will no longer find me desirable." The decreased ability to cope with the removal of the breast is an example of which of the following? a) Defining characteristics b) NANDA label c) Problem d) Etiology

The nurse has inserted her own beliefs into the interpretation of the data.

wellness

The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this patient is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping?

The nurse should determine the client's normal bowel elimination pattern.

The process of nursing diagnosis carries legal implications for nurses. Which of the following legal responsibilities exists for a nurse who has documented a nursing diagnosis related to a client's kidney failure? a) Coordinating the treatment of the client's kidney failure b) Choosing interventions to resolve the client's kidney failure c) Reporting signs and symptoms related to the client's kidney failure d) Independently managing the client's kidney failure

diagnosing

The purpose of _______ is to identify factors that contribute to or cause health problems (etiologies).

diagnosing

The purpose of _______ is to identify how an individual, group, or community responds to actual or potential health and life processes.

diagnosing

The purpose of _______ is to identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems.

The nurse caring for a morbidly obese client formulates the possible nursing diagnosis, "Imbalanced Nutrition: More than Body Requirements related to excessive food intake as evidenced by morbid obesity." In order to assure the accuracy of the diagnosis, which further step must the nurse take?

Validate with the client that excessive food intake is the cause of the client's obesity.

NANDA

What association meets every 2 years to further progress in defining, classifying, and describing nursing diagnoses?

descriptors

What gives additional meaning to a nursing diagnosis?

What information provides the nurse with accuracy when developing a nursing diagnosis? a) Specific nursing interventions b) A set of lab values c) A set of clinical cues d) Abnormal diagnostic tests

What is meant by impaired state of equilibrium? a) It describes the client's condition b) It is common terminology c) It is a nursing diagnosis d) It assists in planning care

What is the process of gathering and clustering data to draw inferences and propose a diagnosis? a) Analytical reasoning b) Critical thinking c) Recollection d) Diagnostic reasoning

What is the purpose of establishing a nursing diagnosis? a) To meet accreditation criteria b) To identify medical problems c) To collaborate with the physician d) To describe a functional health problem

Which of the following errors has the nurse made in formulating the nursing diagnosis: Pain related to nurse failing to administer pain med in a timely manner AEB client pain rating of 7 out of 10, client guarding abdominal incision, client ambulates slowly. a) Used judgmental language b) Omitted defining characteristics c) Used legally inadvisable terms d) Used a medical diagnosis

Which of the following is a correct guideline to follow when composing a nursing diagnosis statement? a) Place the etiology prior to the client problem and linked by the phrase "related to." b) Incorporate subjective and judgmental terminology. c) Phrase the nursing diagnosis as a client need. d) Place defining characteristics after the etiology and link them by the phrase "as evidenced by."

Which of the following is classified as a nursing diagnosis? a) Esophageal cancer b) Pneumonia c) Cholecystitis d) Grieving

Which of the following nursing diagnoses has the highest priority when caring for an older adult client with Alzheimer's disease? a) Impaired physical mobility b) Impaired memory c) Self-care deficit d) Risk for injury

Which of the following nursing diagnoses is written incorrectly as a result of the health problem and etiology being reversed? a) Pain related to tissue trauma and inflammation AEB client pain rating of 8 out of 10, client guarding abdominal incision, heart rate 109, respiratory rate 28, blood pressure 132/88. b) Risk for Injury related to lack of knowledge of crutch walking c) Risk for Disturbed Body Image related to decreased ability to cope with surgical removal of right breast d) Prolonged Immobility related to impaired skin integrity AEB one-inch diameter open area on right buttocks surrounded by a one-inch margin of redness; wound surface clean and beefy red; no drainage or foul odor detected.

Which of the following reflects the diagnosis phase? a) The nurse performs wound care using sterile technique. b) The nurse documents the client's response to pain medication. c) The nurse sets a tolerable pain rating with the client. d) The nurse identifies that the client does not tolerate activity.

Why is coding important when writing a nursing diagnosis? a) Enhances the professionalism of the nursing process b) Allows for direct reimbursement for nurses c) Provides legal characteristics for licensure d) Evaluates the diagnostic statement for accuracy

Can a nurse develop a nursing diagnosis when there is not enough evidence to support the presence of a problem, but the nurse would like to gather more evidence?

Yes, this defines a possible nursing diagnosis.

wellness

______ nursing diagnoses are clinical judgements about an individual, group, or community in transition from a specific level of this to a higher level. Two cues must be present for a valid diagnosis of this type.

nursing diagnoses

_______ are written to describe patient problems that nurses can treat independently.

A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues provide organization, or:

clustering

The nursing diagnosis taxonomy provides nursing with:

common language

Which example of client care is not the responsibility of the nurse?

confirming a medical diagnosis

The act of analyzing and synthesizing cues requires:

critical thinking

What are related factors?

Describes the conditions, circumstances, or etiologies that contribute to the problem.

What gives additional meaning to a nursing diagnosis? Composition Descriptors Dysfunction Qualifications

Descriptors Descriptors are words used to give additional meaning to a nursing diagnosis.

Identifying related factors helps nurses do what?

Develop specific interventions to resolve the health problem

love and belonging

Because basic needs must be met before a person can focus on higher ones, patient needs may be prioritized according to the following hierarchy from Maslow: physiologic needs, safety needs, _______ needs, self esteem needs, self actualization needs.

self esteem

A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination? Bowel Incontinence Ulcerative Colitis Irritable Bowel Syndrome Small Bowel Obstruction

Bowel Incontinence Bowel incontinence is a NANDA-I-approved nursing diagnosis under the domain of Elimination. Ulcerative colitis, irritable bowel syndrome, and small bowel obstruction are medical diagnoses.

A 57 year-old woman is caring for her 84-year-old mother-in-law. Which statement would lead the nurse to make a nursing diagnosis of caregiver role strain? "I just don't have time to take a shower." "I feel great but wish that I could get more sleep." "My mother-in-law and I go for a walk daily." "My mother-in-law makes dinner on Tuesday's and I cannot stand her cooking."

"I just don't have time to take a shower." Any of these choices could be a clue to caregiver role strain when clustered with other evidence. However, the inability to care for one self strongly indicates that this client is not coping well.

A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment and has had liquid stool and the skin is clean and intact; therefore she selects the nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student has made a diagnostic error for which of the following reasons? 1. Incorrect clustering 2. Wrong diagnostic label 3. Condition is a collaborative problem. 4. Premature closure of clusters

2 Wrong diagnostic label

Identify problems by doing the following:

-Analyzing collected data -Identifying the patient's strengths -Identifying the patient's normal functional level and indicators of actual or potential dysfunction -Formulating a diagnostic statement in relation to this synthesis

What are some examples of descriptors?

-Anticipatory: Realize ahead of time, foresee, predict -Compromised: Made vulnerable to threat -Decreased: Lessened, lesser in size, amount or degree -Deficient: Inadequate in amount, quality, or degree -Delayed: Postponed, impeded, and retarded -Disproportionate: Not consistent with a standard or norm -Disabled: Limited, incapacitated, handicapped -Disorganized: Not properly arranged or positioned -Disturbed: Agitated or interrupted, interfered with -Dysfunctional: Abnormal, incomplete functioning -Effective: Producing the intended or expected effect -Excessive: Characterized by an amount or quantity that is greater than that necessary, desirable, or useful

A nursing diagnosis has which parts? Select all that apply. Risk factors Defining characteristics Related factors Chief complaint Descriptors Definition

-Defining characteristics - Related factors -Descriptors -Definition Defining characteristics are the observable "cues or inferences that cluster as manifestations of an actual illness or wellness health state." (NANDA, 2009). Related factors describe the condition, circumstances, or etiologies that contribute to the problem. Descriptors are words used to give additional meaning to a nursing diagnosis. Each approved NANDA-I nursing diagnosis has a definition that describes the characteristics of the human response under consideration. Rick factors describe the clinical cues in risk nursing diagnoses and are not used in actual nursing diagnosis.

The NANDA-I taxonomy has three levels. What are they?

-Domains, classes, and nursing diagnosis

In the nursing diagnosis phase the nurse does the following:

-Identifies patterns -Validates the diagnosis -Formulates the nursing diagnosis statement

A nursing diagnosis of Ineffective Airway Clearance has been chosen by the nurse caring for a client with respiratory problems. Which assessment data would be appropriate evidence of this diagnosis? Select all that apply. Ineffective cough Wheezes auscultated over all lung fields Labored respirations Viral pneumonia Oxygen at 3 liters/min per nasal cannula

-Ineffective cough -Wheezes auscultated over all lung fields -Labored respirations An ineffective cough, abnormal breath sounds, and labored respirations are all indications of ineffective airway clearance. Viral pneumonia is a medical diagnosis. Oxygen being administered per nasal cannula is a treatment for respiratory problems.

A nurse is planning a class for hospital nurses on the use of nursing diagnoses in client care. When discussing possible arguments that have been made against the use of nursing diagnoses, what information will the nurse include? Select all that apply. Nursing diagnoses apply limits to nursing practice. Nursing diagnoses discourage innovative thinking. Nursing diagnoses focus on negative client factors. Nursing diagnoses promote a paternalistic attitude from health care providers. Nursing diagnoses are confused with medical diagnoses in the health care community.

-Nursing diagnoses apply limits to nursing practice. -Nursing diagnoses discourage innovative thinking. -Nursing diagnoses focus on negative client factors. -Nursing diagnoses promote a paternalistic attitude from health care providers. Arguments against using nursing diagnoses include some nurses' beliefs that nursing diagnoses promote a standardized method of care with little thought to client's individual needs. Nursing diagnoses do focus on the client's deficits and not their strengths. Nursing diagnoses encourage health care providers to put a label on client's behavior & promotes an "I know best" mentality. Members of the health care community do not confuse medical and nursing diagnoses.

The nurse is formulating nursing diagnoses pertaining to a client with pancreatic cancer. Which of the following factors would the nurse identify as strengths of the client? Select all that apply. The client states that no one should ever ask for help from others. The client has been accompanied by family members to every appointment. The client states a belief in a reward in heaven after death. The client has a long history of health problems. The client has demonstrated effective coping skills in the past.

-The client has been accompanied by family members to every appointment. -The client states a belief in a reward in heaven after death. -The client has demonstrated effective coping skills in the past. The client's support of family members, a belief in an afterlife, and demonstration of effective coping skills in the past are indications that the client will be able to cope with this illness. The client's belief in never asking for help will cause excessive isolation from others. The client's long history of health problems may have exhausted his physical and mental resources.

Review the following problem-focused nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.) 1. Impaired Skin Integrity related to physical immobility 2. Fatigue related to heart disease 3. Nausea related to gastric distention 4. Need for improved Oral Mucosa Integrity related to inflamed mucosa 5. Risk for Infection related to surgery

1, 3 Impaired skin integrity related to physical immobility Nausea related to gastric distention

A nurse reviews data gathered regarding a patient's ability to cope with loss. The nurse compares the defining characteristics for Ineffective Coping with those for Readiness for Enhanced Coping and selects Ineffective Coping as the correct diagnosis. This is an example of the nurse avoiding an error in: (Select all that apply.) 1. Data collection. 2. Data clustering. 3. Data interpretation. 4. Making a diagnostic statement. 5. Goal setting.

1, 3 Data collection Data interpretation

The use of standard formal nursing diagnostic statements serves several purposes in nursing practice, including which of the following? (Select all that apply.) 1. Defines a patient's problem, giving members of the health care team a common language for understanding the patient's needs 2. Allows physicians and allied health staff to communicate with nurses how they provide care among themselves 239 3. Helps nurses focus on the scope of nursing practice 4. Creates practice guidelines for collaborative health care activities 5. Builds and expands nursing knowledge

1, 3, 5 Defines a patient's problem, giving members of the health care team a common language for understanding the patient's needs Helps nurses focus on the scope of nursing practice Builds and expands nursing knowledge

A nurse is getting ready to assess a patient in a neighborhood community clinic. He was newly diagnosed with diabetes just a month ago. He has other health problems and a history of not being able to manage his health. Which of the following questions reflects the nurse's cultural competence in making an accurate diagnosis? (Select all that apply.) 1. How is your diabetic diet affecting you and your family? 2. You seem to not want to follow health guidelines. Can you explain why? 3. What worries you the most about having diabetes? 4. What do you expect from us when you do not take your insulin as instructed? 5. What do you believe will help you control your blood sugar?

1, 3, 5 How is your diabetic diet affecting you and your family? What worries you the most about having diabetes? What do you believe will help you control your blood sugar?

In which of the following examples are nurses making diagnostic errors? (Select all that apply.) 1. The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data 2. The nurse who measures joint range of motion after the patient reports pain in the left elbow 3. The nurse who considers conflicting cues in deciding which diagnostic label to choose 4. The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping 5. The nurse who makes a diagnosis of Ineffective Airway Clearance related to pneumonia.

1, 4, 5 The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping The nurse who makes a diagnosis of ineffective airway clearance related to pneumonia

What are the two phases of diagnostic validation?

1. Cue clusters that have been interpreted are compared with norms for the patient and for patients in general 2. The specific nursing diagnosis is evaluated for its nursing research base.

The nursing diagnosis Impaired Parenting related to mother's developmental delay is an example of a(n): 1. Risk nursing diagnosis. 2. Problem-focused nursing diagnosis. 3. Health promotion nursing diagnosis. 4. Wellness nursing diagnosis.

2 Problem-focused nursing diagnosis

A nurse is assigned to a new patient admitted to the nursing unit following admission through the emergency department. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order, beginning with the first step. 1. Considers context of patient's health problem and selects a related factor 2. Reviews assessment data, noting objective and subjective clinical information 3. Clusters clinical cues that form a pattern 4. Chooses diagnostic label

2, 3, 4 Reviews assessment data, noting objective and subjective clinical information Clusters clinical cues that form a pattern Chooses diagnostic label

Which of the following nursing diagnoses is stated correctly? (Select all that apply.) 1. Fluid Volume Excess related to heart failure 2. Sleep Deprivation related to sustained noisy environment 3. Impaired Bed Mobility related to postcardiac catheterization 4. Ineffective Protection related to inadequate nutrition 5. Diarrhea related to frequent, small, watery stools.

2, 4 Sleep deprivation related to sustained noisy environment Ineffective protection related to inadequate nutrition

How many nursing diagnosis are there as of 2009?

206 that have been accepted by NANDA-I

A nursing student reports to a lead charge nurse that his assigned patient seems to be less alert and his blood pressure is lower, dropping from 140/80 to 110/60. The nursing student states, "I believe this is a nursing diagnosis of Deficient Fluid Volume." The lead charge nurse immediately goes to the patient's room with the student to assess the patient's orientation, heart rate, skin turgor, and urine output for last 8 hours. The lead charge nurse suspects that the student has made which type of diagnostic error? 1. Insufficient cluster of cues 2. Disorganization 3. Insufficient number of cues 4. Evidence that another diagnosis is more likely

3 Insufficient number of cues

A nurse in a mother-baby clinic learns that a 16-year-old has given birth to her first child and has not been to a well-baby class yet. The nurse's assessment reveals that the infant cries when breastfeeding and has difficulty latching on to the nipple. The infant has not gained weight over the last 2 weeks. The nurse identifies the patient's nursing diagnosis as Ineffective Breastfeeding. Which of the following is the best "related to" factor? 1. Infant crying at breast 2. Infant unable to latch on to breast correctly 3. Mother's deficient knowledge 4. Lack of infant weight gain

3 Mother's deficient knowledge

A nurse interviewed and conducted a physical examination of a patient. Among the assessment data the nurse gathered were an increased respiratory rate, the patient reporting difficulty breathing while lying flat, and pursed-lip breathing. This data set is an example of: 1. Collaborative data set. 2. Diagnostic label. 3. Related factors. 4. Data cluster.

4 Data cluster

A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is Diarrhea related to intestinal colitis. For which of the following reasons is this an incorrectly stated diagnostic statement? 1. Identifying the clinical sign instead of an etiology 2. Identifying a diagnosis on the basis of prejudicial judgment 3. Identifying the diagnostic study rather than a problem caused by the diagnostic study 4. Identifying the medical diagnosis instead of the patient's response to the diagnosis.

4 Identifying the medical diagnosis instead of the patient's response to the diagnosis

A nurse assesses a young woman who works part time but also cares for her mother at home. The nurse reviews clusters of data that include the patient's report of frequent awakenings at night, reduced ability to think clearly at work, and a sense of not feeling well rested. Which of the following diagnoses is in the correct PES format? 1. Disturbed Sleep Pattern evidenced by frequent awakening 2. Disturbed Sleep Pattern related to family caregiving responsibilities 3. Disturbed Sleep Pattern related to need to improve sleep habits 4. Disturbed Sleep Pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested

4 Disturbed sleep pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested

A client is brought to the emergency room in an unconscious condition, accompanied by his son. The client is having respiratory arrest and is put on a ventilator. What is the most appropriate nursing diagnosis for this client? a) Ineffective breathing pattern b) Impaired spontaneous ventilation c) Impaired gas exchange d) Ineffective airway clearance

A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues provide organization or ... a) Diagnosing b) Grouping c) Categorizing d) Clustering

disturbed body image related to the incision scar

A client who has to undergo a parathyroidectomy is worried that he may have to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan?

A client who is scheduled for coronary angioplasty is concerned if the surgery is safe and wonders whether it would be beneficial to him. Which of the following nursing diagnoses relates to this client's condition? a) Anxiety related to fear of death during surgery b) Knowledge deficit: treatment regimen related to surgical outcomes c) Risk related to unknown outcome of surgery d) Ineffective coping related to anxiety and fear of surgery

A client with a new colostomy often becomes short and sarcastic when nurses attempt to teach him about the management of his new appliance. The nurse has consequently documented "Noncompliance related hostility" on the client's chart. What mistake has the nurse made when choosing and documenting this nursing diagnosis? a) Identifying a problem without corroborating evidence in the statement b) Identifying a problem that cannot be changed c) Neglecting to identify potential complications related to the problem d) Presuming to know the factors contributing to the problem

Each piece of the patient information is considered what?

A clinical cue; a set of clinical cues forms a cluster that is present if the diagnosis is accurate

What is a nursing diagnosis?

A clinical judgement about individual, family or community responses to actual or potential health problems/ life processes. It provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.

Formulating an accurate nursing diagnosis is what?

A clinical judgement, but nursing diagnosis should not be written judgmentally.

A male client age 67 years has right lower quadrant pain that has been diagnosed as appendicitis and subsequently treated by open appendectomy. How should the nurse document a potential complication related to this patient's diagnosis and treatment? a) "Risk for respiratory complications due to anesthesia" b) "Potentially complicated respiration as a result of surgery" c) "PC: Atelectasis related to surgery" d) "Client is at risk of impaired lung function due to anesthesia."

A nurse is caring for a client admitted with dehydration after completing a triathlon in a hot, dry climate. The nurse identifies an appropriate nursing diagnosis for this client as "Deficient fluid volume related to insufficient fluid intake as evidenced by blood pressure 84/46, heart rate 145, concentrated urine, and client stating that he drank 200 mL of water during the 4-hour event." Identify the problem statement in this nursing diagnosis. a) Insufficient fluid intake b) Hot, dry climate c) Deficient fluid volume d) Blood pressure 84/46, heart rate 145, concentrated urine, and tented skin turgor

A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain that is interfering with her ability to ambulate. The nurse accurately documents which of the following as a nursing diagnosis in the client's records? a) Ineffective physical mobility due to pain b) Ineffective movement related to arthritis c) Impaired physical mobility related to pain d) Impaired movements due to pain

A nurse is caring for an elderly client who is scheduled for a cystoscopy the next day to determine the cause of an over-distended bladder. The client informs the nurse that this the first time that she has been admitted to a healthcare facility for an illness. Which of the following is a diagnostic label the nurse would use to formulate the nursing diagnosis? a) Physical immobility b) Anxiety c) Over-distention d) Compromised

A nurse is educating a client about care to be taken in nephrotic syndrome. The client expresses that the teachings are of no use because the disease is not curable. What nursing diagnosis should the nurse write with regard to the client's concern? a) Impaired comfort b) Disturbed body image c) Risk for powerlessness d) Ineffective coping

Problems can occur in diagnostic validation because of what?

A nurse's limited experience, lack of knowledge base about the nursing diagnosis, or insufficient characteristics of a diagnosis

A pregnant client asks the nurse for information on breastfeeding her baby. What type of nursing diagnosis would the nurse formulate? An actual nursing diagnosis A risk nursing diagnosis A possible nursing diagnosis A wellness diagnosis

A wellness diagnosis The client is seeking information related to healthy practices. Wellness diagnoses are formulated to assist the client to meet that need. The client has no health problem or possible problem, so an actual diagnosis, a risk diagnosis, and a possible diagnosis are inappropriate.

According to Maslow's hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure? a) Impaired urinary elimination b) Ineffective airway clearance c) Ineffective coping d) Risk for body image disturbance

A nurse is using Gordon's functional health patterns as an organizing framework for client assessment. The client has significant problems related to breathing for which the nurse identifies several nursing diagnostic labels, including ineffective breathing pattern and impaired gas exchange. The nurse understands that these nursing diagnoses would be organized under which functional pattern? Activity-exercise Nutritional-metabolic Coping-stress tolerance Congnitive-perceptual.

Activity-exercise Nursing diagnoses involving ineffective breathing pattern and impaired gas exchange would be organized under the pattern of activity-exercise. Nutritional-metabolic involves nursing diagnoses associate with weight, eating, fluids, and skin and tissue integrity. Coping-stress tolerance addresses coping, resilience, suicide, and self-mutilation. Cognitive-perceptual addresses pain, neurologic issues, impulse control, knowledge, and decision-making.

Actual "Ineffective Airway Clearance related to thick tracheobronchial secretions" is an actual diagnosis because it describes a human response to a health problem that is being manifested. A wellness diagnosis is a diagnostic statement that describes the human response to levels of wellness in an individual, family, or community that has a potential for enhancement to a higher state. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. A possible nursing diagnosis is made when not enough evidence supports the presence of the problem, but the nurse concludes that it is highly probable and wants to collect more information.

"Acute Pain related to instillation of peritoneal dialysate as evidenced by client wincing and grimacing during procedure, client description of experience as 'stabbing'" is an example of which type of nursing diagnosis? Actual diagnosis Risk diagnosis Wellness diagnosis Potential diagnosis

Actual diagnosis This is an actual diagnosis as it contains the diagnostic label (acute pain), related factors (instillation of peritoneal dialysate), and defining characteristics (wincing, grimacing during procedure, stabbing). Risk Diagnosis is a two-part statement that includes diagnostic label and risk factors. Wellness diagnosis is one-part statement that includes diagnostic label. Potential diagnosis is a two-part statement that includes diagnostic label and unknown related factors.

The nurse recognizes that health problems that can be prevented by independent nursing interventions are called what? Dependent nursing diagnoses Actual or potential nursing diagnoses Collaborative nursing diagnoses Syndrome nursing diagnoses

Actual or potential nursing diagnoses Nursing diagnoses are established based on actual or potential health problems that are identified by the nurse and can be independently addressed. Collaborative diagnoses are selected when the nurse needs to work with another member of the health care team in order to assist the client in resolving the health issue. Dependent nursing diagnoses require a specific written order from the primary health care provider in order to be executed by the nurse. Syndrome nursing diagnoses address a cluster of actual or risk diagnoses that are predicted to be present as a result of a certain event or situation.

What does a nursing diagnosis describe?

An actual risk, or wellness human response to a health problem that nurses are responsible for treating independently. It describes the patient's response to the disease process, developmental stage, or life process and provide a convenient way to communicate nursing therapies or interventions.

An elderly female patient's venous ulcer has become foul-smelling after she began using strips of a sheet to dress the wound when she ran out of sterile dressing supplies. How should the nurse document a nursing diagnosis statement related to this patient's circumstances? a) "Infection related to impaired aseptic technique" b) "Risk for sepsis related to local infection." c) Risk for infection related to knowledge deficit" d) "Knowledge deficit due to risk for infection"

What is a descriptor?

Are words used to give additional meaning to a nursing diagnosis. They describe changes in condition, state of the patient, or some qualification of the specific nursing diagnosis. They accompany the labels.

safety

Because basic needs must be met before a person can focus on higher ones, patient needs may be prioritized according to the following hierarchy from Maslow: physiologic needs, _______ needs, love and belonging needs, self esteem needs, self actualization needs.

What are terms that can be used to describe the related factors?

Associated with, related to, or contributing to

A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify? Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor Homelessness Syndrome related to lack of housing as evidenced by visibly soiled clothing Inadequate Hygiene related to homelessness as evidenced by client's stink Impaired Impulse Control related to poor socioeconomic conditions as evidenced by visibly soiled clothing

Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor The most appropriate diagnosis would be "Bathing Self-care Deficit. The client is homeless and would not be able to access bathroom facilities. Homelessness has not been identified as a syndrome and there is only evidence of one problem. Inadequate hygiene has not been identified as a nursing diagnosis; furthermore, the word "stink" is an offensive term which must be avoided in nursing documentation. There is no evidence to suggest that the client has any issues with impulse control.

physiologic

Because basic needs must be met before a person can focus on higher ones, patient needs may be prioritized according to the following hierarchy from Maslow: _______ needs, safety needs, love and belonging needs, self esteem needs, self actualization needs.

What is a taxonomy?

Classification system to provide a structure for nursing practice.

What is the term risk factor used to describe?

Clinical cues in risk nursing diagnoses and are not used for actual nursing diagnoses.

Which of the following is an example of a nursing diagnosis? Constipation Hypoglycemia Dehydration Depression

Constipation Constipation is a nursing diagnosis included in the Elimination domain. Hypoglycemia, dehydration, and depression are examples of medical diagnoses or medical pathology.

A client reports not having a bowel movement for 7 days, followed by a day of small, loose stools. How does the nurse define the health problem? Constipation related to irregular evacuation patterns Readiness for Enhanced Nutrition related to constipation Bowel incontinence related to depressive state Diarrhea related to client report of small, loose stools

Constipation related to irregular evacuation patterns The client report of constipation followed by loose stools, which indicates a health problem, may exist and establishes the need for professional care. The nurse must decide if the problem is a nursing diagnosis or a collaborative problem, and establish a plan of care accordingly. None of the alternate diagnoses are supported by the data available.

A newly graduated nurse is unable to determine the significance of data obtained during an assessment. What would be the nurse's most appropriate action?

Consult with a more experienced nurse.

A newly graduated nurse is unable to determine the significance of data obtained during an assessment. What would be the nurse's most appropriate action? The parent states, "I make sure that I get regular exercise." The parent states, "A member of my church gives me a break twice a week." The parent states, "I cannot allow anyone else to help because they won't do it right." The parent states, "I attend support group meetings when I am able to go."

Consult with a more experienced nurse. A newly graduated nurse does not have the experience to interpret all data. The nurse must recognize when a consult with a more experienced nurse is needed. There is no evidence that the nurse needs to collect more data. The data must be documented, but if the data is significant, it may harm the client if no action is taken. There is no need to contact the health care provider at this time.

The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this baby, but I have always believed that abortion is a sin. I don't know what to do." What nursing diagnosis would be most appropriate for the nurse to formulate? Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement Hopelessness related to inability to decide a course of action as evidenced by the client's statement Complicated Grieving related to mental trauma as evidenced by the client's inability to make a decision Ineffective Coping related to rape trauma syndrome as evidenced by client's inability to make a decision

Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement The client's statement indicates that it is difficult for the client to reach a decision because of her moral beliefs. The client is not expressing hopelessness or ineffective coping. The client may be suffering from rape trauma syndrome, but the assessment data does not lead to that diagnosis.

What is a medical diagnosis?

Describes a disease or pathology of specific organs or body systems. Convey information about the signs and symptoms of disease processes and provide a convenient means for communicating treatment requirements. The physician focuses on treating the underlying pathology.

What is an actual nursing diagnosis?

Describes a human response to a health problem that is being manifested. Accurate: Impaired physical mobility related to pain

What is risk nursing diagnosis?

Describes human responses to health conditions/ life processes that may develop in a vulnerable individual, family, or community. It is supported by risk factors that contribute to increased vulnerability. Accurate: Risk for aspiration related to reduced level of consciousness

A female client undergoing chemotherapy for breast cancer has lost all her hair. The client states, "I cannot stand to see myself without hair. I am disgusting." What would be the most appropriate nursing diagnosis for the nurse to use to address this client's problem? Disturbed Body Image related to breast cancer Disturbed Body Image related to loss of hair Disturbed Body Image as evidenced by client's refusal to look at self Disturbed Body Image as evidenced by client's negative comments

Disturbed Body Image related to loss of hair The client has a problem with her body image because she has lost her hair. The evidence would be the client's statement. The etiology cannot be a medical diagnosis, so the etiology of breast cancer would be incorrect. The other two statements do not contain an etiology. Nursing diagnoses must identify an etiology to direct the client's care.

Risk factors are what?

Environmental factors and physiological, psychological, genetic, or chemical elements that increase the vulnerability of an individual, family or community to an unhealthy event

A client, whose care plan includes a nursing diagnosis of "Risk for infection related to a disruption of skin integrity secondary to abdominal surgery", is displaying redness, edema, and warmth at the surgical site. What would be the nurse's most appropriate revision of the care plan? Formulate the collaborative problem "PC: Infection related to disrupted skin integrity." Revise the nursing diagnosis to include prescribed medication for infection. Formulate the medical diagnosis "Wound infection related to infectious processes." Revise the nursing diagnosis to "Infection as evidenced by redness, edema, and warmth at the surgical site."

Formulate the collaborative problem "PC: Infection related to disrupted skin integrity." When the client is at risk for infection, nurses can care for the client with independent nursing interventions. Once the client becomes infected, antibiotics will be needed which must be prescribed by the physician, which necessitates a collaborative diagnosis. The nursing diagnosis never addresses prescribed medication. Nurses do not formulate medical diagnoses. Actual infection is no longer an independent nursing problem.

Which of the following is classified as a nursing diagnosis? Esophageal cancer Cholecystitis Grieving Pneumonia

Grieving Grieving is a nursing diagnosis per the latest NANDA-I Taxonomy. The other choices are medical diagnoses.

High Risk for Injury related to unsafe home environment

A nurse is caring for a toddler who has been treated on two different occasions for lacerations and contusions due to the parents' negligence in providing a safe environment. What is an appropriate nursing diagnosis for this client? High Risk for Injury related to abusive parents High Risk for Injury related to impaired home management Child Abuse related to unsafe home environment High Risk for Injury related to unsafe home environment

High Risk for Injury related to unsafe home environment The nursing diagnosis "High Risk for Injury related to unsafe home environment" is appropriate because it contains the NANDA-I nursing diagnosis problem statement and the etiology of the problem. High Risk for Injury related to abusive parents is accusatory and may not be accurate. High Risk for Injury related to impaired home management does not accurately identify the etiology of the problem. Child Abuse is not a NANDA-I approved nursing diagnosis.

A client recently diagnosed with pancreatic cancer tells the nurse, "I don't see any hope for my future." What would be the most appropriate nursing diagnosis for the nurse to formulate to address this health problem? Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis Disturbed Self-Concept related to pancreatic cancer diagnosis Ineffective Health Maintenance related to being overwhelmed by cancer diagnosis Knowledge Deficit: Cancer treatment options related to new diagnosis

Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis The client is expressing a lack of hope for the future, which makes "Hopelessness" an appropriate nursing diagnosis. There is no evidence that the client has a disturbed self-concept. There is no evidence that the client is not effectively caring for health. The client does not verbalize a desire to learn about treatment options.

Cue clustering brings together cues that what?

If viewed separately would not convey the same meaning.

A nurse is interviewing an older adult client who has experienced a drastic weight loss following a CVA (cerebrovascular accident). The client states, "I have trouble getting groceries since I can no longer drive, so I don't have much food in the house." Based on this evidence, what would be the most appropriate nursing diagnosis? Imbalanced nutrition: Less than Body Requirements related to difficulty in procuring food Imbalanced Nutrition: Less than Body Requirements related to drastic weight loss Imbalanced Nutrition: Less than Body Requirements related to cerebrovascular accident Imbalanced nutrition: Less than Body Requirements related to decreased appetite

Imbalanced nutrition: Less than Body Requirements related to difficulty in procuring food The client relates the drastic weight loss to the inability to bring food into the house. The client's statement is the most appropriate etiology for the nursing diagnosis. Drastic weight loss is the evidence of imbalanced nutrition. Cerebrovascular accident is the medical diagnosis. The client could have had a CVA and still have the ability to grocery shop. There is no evidence that the client has lost appetite.

A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain that is interfering with her ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records? Ineffective movement related to arthritis Impaired movements due to pain Impaired physical mobility related to pain Ineffective physical mobility due to pain

Impaired physical mobility related to pain "Impaired physical mobility related to pain" is the correct nursing diagnosis because it consists of an accurate descriptor, diagnostic label, and related factor. "Ineffective movement related to arthritis" is an incorrect entry because the descriptor is incorrect and the diagnostic label is not approved. "Impaired movement due to pain" is an inaccurate entry because the descriptor is inaccurate and the related factor is not written using approved words. "Ineffective physical mobility due to pain" has an erroneous diagnostic label and the related factors are written incorrectly.

In the development and documentation of a nursing diagnosis, the nurse should follow which of the following guidelines? a) Due to a lack of standard terms, the use of a computerized program to develop nursing diagnoses is discouraged in many hospitals and nursing facilities. b) Nurses should use only NANDA-accepted terms to state diagnoses and develop a nursing care plan. c) Accepted terms for nursing diagnoses may vary according to a school, employer, or specialty organization. d) The use of NANDA nursing diagnoses is necessary to communicate the purposes of research and patient care.

Analysis of cue clusters can be impeded by?

Incorrect clustering of data and misinterpretation of cue clusters.

A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis? Bronchial Pneumonia Ineffective Airway Clearance Acute Dyspnea Asthma Attack

Ineffective Airway Clearance Since wheezing, shortness of breath, and coughing are signs of a constricted airway, the nursing diagnosis of ineffective airway clearance is the appropriate diagnosis. Bronchial pneumonia and asthma attack are both medical diagnoses. Acute dyspnea is a symptom.

A client with diabetes mellitus has been admitted to the hospital in diabetic ketoacidosis. During the admission assessment of the client, the nurse learns that the client is not following the prescribed therapeutic regimen. The client states, "I don't really have diabetes. My doctor overreacts." What is the most appropriate diagnosis for this client's health problem? Risk for Unstable Blood Glucose related to client's reluctance to manage the diabetic regimen Ineffective Health Maintenance related to client's denial of illness Risk for Injury related to client's mismanagement of disease Ineffective Coping related to client's inability to manage the diabetic regimen

Ineffective Health Maintenance related to client's denial of illness The most appropriate diagnosis is Ineffective Health Maintenance related to client's denial of illness. The data point to the fact that the client is not managing the diabetes, since the client is denying that a problem exists. The client is at risk for unstable blood glucose, but the client's denial is the underlying problem. Risk for Injury relates to safety issues. It is also inappropriate documentation to say the client is "mismanaging" the illness. Ineffective Coping could be an appropriate diagnosis, but the client is not "unable" to manage the illness, just unwilling.

The nurse is caring for a client with AIDS (acquired immune deficiency syndrome) who frequently misses clinic appointments. The client states that transportation to the clinic is very difficult. What would be the nurse's most appropriate diagnosis?

Ineffective health maintenance related to transportation difficulties

What is the major problem in cue clustering?

Insufficient, inaccurate, and inconsistent cues

The specificity can be measured and monitored to what?

Make sure that effective interventions are acknowledged for their contributions to resolving healthcare problems.

The nurse is admitting a client who is unable to identify person, place, or time. In order to properly analyze this data, what action must the nurse take? Determine the client's medical diagnosis for clarification. Interview the client's family to assess the client's usual level of consciousness. Assess the client's vital signs to determine the client's baseline. Ensure precautions are taken to prevent injury to the client.

Interview the client's family to assess the client's usual level of consciousness. In order to properly analyze the assessment data, the nurse must compare the assessment against the client's normal condition. The family is the best informant for a client with decreased level of consciousness. The medical diagnosis is not necessary to determine if the client's condition is abnormal. Vital signs should be obtained, but the vital signs will not give an indication of the client's usual level of consciousness. Ensuring the client's safety is an important nursing intervention, but will not assist in analyzing the data.

What is wellness nursing diagnosis?

Is a diagnostic statement that describes human responses to levels of wellness in an individual, family, or community, that have a readiness for enhancement to a higher state. Ex. Readiness for enhanced spiritual well-being

What is a definition of nursing diagnosis?

It describes the characteristics of the human response under consideration.

What is a possible nursing diagnosis?

It is made when not enough evidence supports the problem but the nurse thinks that it is highly probable and wants to collect more information. Accurate: Possible impaired adjustment related to unknown etiology.

What is the diagnostic label?

It is the name of the nursing diagnosis as listed in the taxonomy.

A nurse is planning education about prescription medications for a client newly diagnosed with asthma. What nursing diagnosis would be most appropriate for the nurse to select? Knowledge deficit: Medications related to new medical diagnosis Ineffective Airway Clearance related to bronchial constriction Noncompliance related to deficient knowledge of a new medical diagnosis Anticipatory Grieving related to chronic illness management

Knowledge deficit: Medications related to new medical diagnosis To most appropriately address the client's health problem, the nurse should educate the client about the new medications the physician has prescribed to treat the asthma. Ineffective airway clearance refers to the physiologic processes of asthma. There is no evidence of noncompliance. There is no indication that the client is having difficulty dealing with the diagnosis.

A classification system for nursing diagnosis involves what?

Knowledge of nursing practice, theoretical frameworks, and the characteristics of taxonomies

What is validation?

Legitimizes the diagnosis and helps to discover its significance for the patient.

The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action? Notify the physician for additional orders. Document the client's level of consciousness. Consult with another nurse to validate the assessment. Decrease stimulation and allow the client to rest.

Notify the physician for additional orders. The client's decreased level of consciousness could indicate that the client is developing an electrolyte imbalance. The change in the client's status requires notification of the physician. Medication orders are required to treat the electrolyte imbalance. Documenting the level of consciousness is appropriate, but not as the priority action. Another nurse is not necessary to check the nurse's assessment. Decreasing stimulation and allowing the client to rest with no further action may result in harm to the client.

The formulation of nursing diagnoses is unique to the nursing profession. Which statement accurately represents a characteristic of diagnosing?

Nurses write nursing diagnoses to describe client problems that nurses can treat.

A nurse documents the following in the client chart: Risk for Decreased Cardiac Output related to myocardial ischemia. This is an example of what aspect of client care? Nursing diagnosis Nursing assessment Medical diagnosis Collaborative problem

Nursing diagnosis The nursing diagnosis statement is worded by stating the client problem (using NANDA-I approved diagnoses) that the nurse is able to treat followed by the etiology of the problem. Nursing assessment refers to the collection of data. A medical diagnosis identifies diseases, whereas nursing diagnoses focus on unhealthy responses to health and illness. Nurses cannot treat medical diagnoses independently. Collaborative problems are the primary responsibility of nurses. Unlike nursing diagnoses, with collaborative problems, the prescription for treatment comes from nursing, medicine, and other disciplines.

Wellness diagnosis

One-part statement includes diagnostic label Ex. Readiness for enhanced spiritual well-being

Nursing diagnosis provides a means of communicating nursing requirements for patient care to who?

Other nurses, the healthcare team, and the public

A client has been diagnosed with a recent myocardial infarction. What collaborative problem would be the priority for the nurse to address? PC: Decreased cardiac output related to cardiac tissue damage PC: Disturbed body image related to decreased activity tolerance PC: Activity intolerance related to decreased oxygenation capacity PC: Fear related to new diagnosis of myocardial infarction

PC: Decreased cardiac output related to cardiac tissue damage All these collaborative problems may be indicated for a client with a recent myocardial infarction; however, priority must be given to life threatening issues. Decreased cardiac output is life threatening so it must be the priority concern.

What are collaborative health problems?

Refer to actual or potential physiologic complications that can result from disease, trauma, treatment, or diagnostic studies for which nurses intervene in collaboration with personnel of other disciplines.

The nurse has assumed that having a sexually transmitted infection means the client is sexually promiscuous.

A client admitted for a surgical procedure tells the nurse, "I am very worried because I am allergic to latex. I want to make sure that everyone knows this." In order to assure the safety of the client, what nursing diagnosis would the nurse address? Anxiety related to surgical procedure Knowledge Deficit related to surgical procedure Risk for Allergy Response related to latex allergy Risk for Injury related to latex allergy

Risk for Allergy Response related to latex allergy To assure the safety of the client, the nurse must address the risk for an allergic response due to the client's latex allergy. Anxiety refers to a vague feeling of dread; however, the client is responding with fear to a very real threat. There is no evidence that the client does not understand the surgical procedure. Risk for Injury is not an appropriate diagnosis, because it does not adequately address the specific health problem.

A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern? Knowledge Deficit related to effects of chemical plant pollution Deficient Community Health related to chemical plant Risk for Community Contamination related to possible environmental pollution Risk for Infection related to community contamination

Risk for Community Contamination related to possible environmental pollution The nurse has identified a risk diagnosis because of the unknown health effects of the chemical plant on the community. Risk for community contamination would address the broad concerns of the nurse. Knowledge deficit is not appropriate because it has too narrow a focus. Deficient community health is not a NANDA-I diagnosis and the etiology must deal with how the plant may possibly affect the community. Risk for infection has a very narrow focus. The etiology of community contamination has not been proven.

Which is an accurately phrased risk diagnosis? Risk for Impaired Coping as evidenced by client crying. Risk for Fluid Volume Excess related to increased oral intake as evidenced by consuming 3 L of soda. Risk for Pain After Surgery. Risk for Falls related to altered mobility.

Risk for Falls related to altered mobility. Risk for Falls related to altered mobility is an accurately phrased risk diagnosis. It is a two-part statement that contains the diagnostic statement (altered mobility) and risk factors (risk for falls).

Which statement appropriately identifies an at-risk nursing diagnosis for a woman 78 years of age who is confined to bed? Ineffective airway clearance related to bed rest Immobility related to confinement to bed Potential for pneumonia related to inactivity Risk for impaired skin integrity related to bed rest

Risk for impaired skin integrity related to bed rest An at-risk nursing diagnosis, as defined by NANDA-I, "describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community."

What is a premature closure?

Selecting a diagnosis before analyzing pertinent information.

What is a cluster?

Several cues, which is then interpreted and validated.

What is cluster interpretation?

Synthesizing the cue clusters. This requires nurses to see the whole picture and to attach meaning to the cluster looking at the pattern the cluster suggest.

A client diagnosed with advanced lung cancer has a nursing diagnosis of Ineffective Coping. What assessment data would provide evidence to the nurse for this diagnosis? The client asks about hospice services. The client makes funeral plans. The client states, "I am sure the doctors have misdiagnosed me." The client states, "I hope that I am able to attend my daughter's wedding."

The client states, "I am sure the doctors have misdiagnosed me." Denying the illness by stating a belief that the cancer diagnosis is incorrect is evidence that the client is not dealing with the illness. Inquiring about hospice and making funeral plans shows acceptance of the advanced stage of the illness. Stating a hope to attend the daughter's wedding is expressing hope for the future and is evidence of effective coping.

The nurse has identified a nursing diagnosis of "Risk for Impaired Parenting" for a client who has recently learned of her pregnancy. What assessment data would be appropriate to lead the nurse to select this diagnosis? The client states, "I am shocked to find out that I am pregnant." The client states, "I do not plan to tell my family about my pregnancy right away." The client states, "I do not know how to take care of a baby." The client states, "I know that I will have to make some changes in my life."

The client states, "I do not know how to take care of a baby." It is not unusual to feel unprepared to care for baby. However, this warrants the nurse's attention because there is an associated risk of impaired parenting. Being shocked about the pregnancy and making changes in her life are all normal reactions to finding out about a pregnancy and do not necessarily indicate future problems. The nurse must work with the client about her communication with her family, but this does not necessarily mean that her parenting will be compromised.

What does the diagnostic label describe?

The essence of the problem using as few words as possible.

The term nursing diagnosis serves as both what?

The label for and the action of describing a patient's health problems.

The nurse is caring for a client who has been diagnosed with a sexually transmitted infection (STI). The nurse plans to address the nursing diagnosis of Risk Prone Behavior. What assumption has the nurse made? The nurse has assumed that having a sexually transmitted infection means the client is sexually promiscuous. The nurse has assumed that the client needs education to decrease the likelihood of repeated infection. The nurse has assumed that having a sexually transmitted infection means the client is unaware of the risks of unprotected sex. The nurse has assumed that the client does not understand the complications of sexually transmitted infections.

The nurse has assumed that having a sexually transmitted infection means the client is sexually promiscuous. Risk Prone Behavior identifies habits of the client that are dangerous. Being sexually promiscuous would be a dangerous behavior. Risk prone behavior does not mean that the client is not knowledgeable or needs further instructions about complications.

A nurse who believes strongly that women should make their own decisions is caring for a female client from a culture where women defer decisions to their husbands. Based on the client's insistence that her husband make all decisions for her, the nurse formulates a nursing diagnosis of "Dysfunctional Family Processes." What type of nursing diagnosis error has the nurse made? The nurse has not selected the correct nursing diagnosis to address this problem. The nurse has inserted her own beliefs into the interpretation of the data. The nurse is not addressing the reason the client is seeking health care. The nurse needs further evidence to validate this diagnosis.

The nurse has inserted her own beliefs into the interpretation of the data. The nurse has made an error by using her own beliefs that women should make autonomous decisions. She is taking a paternalistic attitude toward the client's cultural beliefs. There is no health care problem, so no nursing diagnosis is necessary. The nurse is not addressing the reason the client is seeking health care, but that is not an issue at this time. The nurse would need further evidence to make this nursing diagnosis; however, there is no evidence to make the diagnosis at all.

When reviewing the client's history, the nurse notes that it has been recorded that the client's last bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "Constipation," what assessment must the nurse make? The nurse should assess the client's dietary habits. The nurse should assess the client's bowel sounds. The nurse should determine the client's normal bowel elimination pattern. The nurse should determine the standard bowel elimination pattern for the client's age.

The nurse should determine the client's normal bowel elimination pattern. In order to validate the diagnosis, the nurse must determine what is the normal for the client. Dietary habits may contribute to the constipation, but do not evidence the nursing diagnosis. Assessing bowel sounds would be important data, but would not evidence the diagnosis of constipation. There is no standard elimination pattern; it is highly individualized.

During morning report, the night nurse tells the day nurse that the client refused to allow the technician to draw blood for laboratory testing. What step would be essential for the day nurse to complete before selecting a nursing diagnosis to address this issue? The nurse should determine the length of time the client has been in the hospital. The nurse should determine what laboratory tests are critical at this time. The nurse should determine the reason for the client's refusal. The nurse should determine the client's last laboratory results.

The nurse should determine the reason for the client's refusal. Before addressing the issue, the nurse must determine why the client refused the lab draw. It is essential to know the cause before planning how to address the issue. It is immaterial how long the client has been in the hospital, what laboratory tests are critical, or what the client's last results were.

A client who gave birth yesterday refuses to eat the food provided by the hospital. She states that she must eat special food brought from home by her family. How would the nurse most appropriately address this situation? The nurse should plan no action because the client is not exhibiting a health problem. The nurse should formulate a possible nursing diagnosis and make further observations. The nurse should formulate an active nursing diagnosis and plan interventions to correct the problem. The nurse should formulate a collaborative problem and consult with the physician and dietitian.

The nurse should plan no action because the client is not exhibiting a health problem. Many cultures require the new mother to eat specially prepared food. The client is simply following her own cultural practices. No problem exists and no plan is indicated to address it.

After collecting relevant information about patient's, nurses need to analyze and interpret the data as a result of this this interpretation is what?

The nursing diagnosis

Professions require a sound scientific base what is it?

The nursing process

During a home health care visit, the nurse identifies a nursing diagnosis of Caregiver Role Strain for a parent who is caring for a child dependent on a ventilator. What subjective assessment data would support the nurse's diagnosis?

The parent states, "I cannot allow anyone else to help because they won't do it right."

By focusing attention on the actual or potential health needs of patients nursing diagnoses increases what?

The specificity of nursing interventions for each patient.

What are defining characteristics?

They are observable cues or interferences that cluster as manifestations of an actual illness or wellness health state, or nursing diagnosis

Actual nursing diagnosis

Three part statement includes diagnostic label, related factors, and defining characteristics Ex. Acute pain related to surgical trauma and inflammation as evidenced by grimacing and verbal reports of pain

What is the purpose of the nursing diagnosis?

To identify problems and synthesize the information gathered during the nursing assessment

What is the purpose of cue clustering?

To take individual cues and group them to derive meaning

A nurse has identified a risk nursing diagnosis for a client. When writing this diagnosis, the nurse would write a statement consisting of how many parts?

Two

Possible nursing diagnosis

Two-part statement includes diagnostic label and related factors (unknown) Ex. Possible self-esteem disturbances related to unknown etiology

Risk nursing diagnosis

Two-part statement includes diagnostic label and risk factors. Ex. Risk for infection related to surgery and immunosuppression

When does inaccuracy in clustering occur?

When nurses are unfamiliar with diagnoses or when the cues for various diagnoses overlap.

When does misinterpretation of cue clusters occur?

When the nurse fails to recognize the correct pattern.

risk

______ nursing diagnoses are clinical judgements that an individual, family, or community is more vulnerable to develop the problem than others in the same situation.

possible

______ nursing diagnoses are statements describing a suspected problem for which additional data are needed. Additional data are used to confirm or rule out suspected problem.

actual

_______ nursing diagnoses represent a problem that has been validated by the presence of major defining characteristics. This type of diagnosis has four components: label, definition, defining characteristics, and related factors.

The nurse is aware that development of nursing diagnoses are: both within the nursing scope of practice and are client focused. collaborative in nature and dependent on the medical diagnosis. based on assessment data and the primary care provider's input. dictated by the medical diagnoses and change day by day.

both within the nursing scope of practice and are client focused. Nursing diagnoses may change from day to day as the client's responses change. Collaboration is used in the management of nursing care. However, selecting a nursing diagnosis is a function of nursing.

A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues provide organization, or: categorizing. diagnosing. grouping. clustering.

clustering Cue clustering brings together cues that if viewed separately would not convey the same meaning.

Which example of client care is not the responsibility of the nurse? monitoring for changes in health status promoting safety and preventing harm; detecting and controlling risks tailoring treatment and medication regimens for each individual confirming a medical diagnosis

confirming a medical diagnosis The nursing scope of practice dictates what is allowed and not allowed when providing nursing care. Confirming a medical diagnosis is not in the scope of nursing practice. Monitoring for changes in a client's health status, promoting safety and preventing harm, and tailoring treatment and medication regimens to the client's schedule of activities are all nursing care responsibilities.

Formulating the nursing diagnostic statement involves writing the label of the actual, risk, wellness, or possible nursing diagnosis that what?

has been made through the nursing diagnostic process.

A nurse is preparing to write a nursing diagnosis for a client. Which activity would the nurse need to do first?

identify the significant data

What is the nurse accountable for, according to state nurse practice acts?

making nursing diagnoses

What is the nurse accountable for, according to state nurse practice acts? managing the care team effectively making nursing diagnoses prescribing PRN (as needed) medications mentoring other nurses

making nursing diagnoses State nurse practice acts have included diagnosis as part of the domain of nursing practice for which nurses are held accountable. Overall management of the care team is not an explicit responsibility of nurses. Nurses generally do not have prescriptive authority. The responsibility for mentorship is not enacted in law.

A nurse makes a nursing diagnosis of Constipation after a client tells her he did not defecate on his last trip to the bathroom. The nurse has no other information on the client's defecation history. This is an example of: inconsistent cues. premature closure. clustering of cues. cluster interpretation.

premature closure. Premature closure is when the nurse selects a nursing diagnosis before analyzing all of the pertinent information in the client's case. The nurse did not investigate any other information in this case before making her diagnosis. Inconsistent cues occur when the meaning attached to one cue may be altered based on another cue. The client did not provide any additional cues for this to be the correct answer. Clustering of cues is a clustering of data.

reporting trends that suggest development of complications

When caring for a client, the nurse identifies and analyzes data to identify nursing diagnoses and collaborative problems. Which action is a priority role of the nurse when caring for a client with collaborative problems? identifying the client's understanding of risk factors resolving health issues through independent nursing measures reporting trends that suggest development of complications managing an emerging problem with the help of another registered nurse

reporting trends that suggest development of complications The nurse should report trends that suggest development of complications to bring to notice the need for collaborative intervention for a client. Collaborative problems are physiologic complications that require both nurse- and physician-prescribed interventions. Actions that exclude members of other disciplines are not characteristic of collaborative problem management. The development of complications is a priority over assessment of the client's knowledge of risk factors, even though these must be assessed.

A nurse is developing a plan of care for a client with a chronic respiratory problem. When developing appropriate nursing diagnoses for this client, the nurse needs to keep in mind that:

the interventions planned must be within the nurse's scope of practice.

What is the purpose of establishing a nursing diagnosis? to describe a functional health problem to collaborate with the physician to identify medical problems to meet accreditation criteria

to describe a functional health problem Establishment of a nursing diagnosis reflects the synthesis of data gathered during a nursing assessment. Gordon suggested a framework for organizing nursing diagnoses based on functional health, thus offering a convenient way to cluster similar diagnoses.

Ch 12: Diagnosing PrepU

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