Chapter 12 (DIAGNOSING) Prep U and ATI

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?

Impaired comfort

Which of the following nursing diagnoses has the highest priority when caring for an older adult client with Alzheimer's disease?

Risk for injury

What is the purpose of establishing a nursing diagnosis?

To describe a functional health problem

What does the nursing diagnosis represent?

What does the nursing diagnosis represent?

While planning care for a client immediately after surgery, the nurse formulates a nursing diagnosis of "Risk for injury." Of the following assessment data, what would the nurse select as an appropriate etiology for the diagnosis? (Select all that apply.)

• Visual deficit • Effects of pain medications • Impaired mobility • Unfamiliarity of hospital environment

A nurse documents the following in the patient chart: Risk for decreased cardiac output related to myocardial ischemia. This is an example of what aspect of patient care?

Nursing diagnosis

A nurse is justified in independently identifying and documenting which of the following diagnoses related to impaired elimination?

Bowel Incontinence

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

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.

The nurse caring for a client with obesity would like to address the possible health problems that can develop related to obesity. To plan care for this client, what type of nursing diagnosis would the nurse formulate?

A risk nursing diagnosis

A client who is a new quadriplegic as the result of a motor vehicle accident, is experiencing multiple physical and emotional problems. To guide the care planning for this client, what type of nursing diagnosis would be most appropriate for the nurse to select?

A syndrome nursing diagnosis

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

A wellness diagnosis

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

The nurse recognizes that health problems that can be prevented by independent nursing interventions are called what?

Actual or potential nursing diagnoses

The nurse enters a postoperative client's room and finds that the client is bleeding profusely from the surgical incision. What would be the nurse's most appropriate initial response?

Apply pressure to the surgical site to decrease bleeding

When planning initial care for a 16-year-old mother of a newborn, the nurse formulates a possible nursing diagnosis of "Risk for ineffective parent-infant attachment related to adolescent parent." What would be the nurse's most appropriate next action?

Assess the client's interactions with her newborn

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

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

The nurse caring for a client diagnosed with melanoma has identified a nursing diagnosis of "Ineffective coping." What subjective assessment data would provide evidence for this nursing diagnosis?

Client's report of increased consumption of alcohol

The nurse is examining the assessment data of a client and diagnoses a problem of impaired tissue perfusion based on the following assessment data cues: left foot cool and pale with capillary refill > 3 seconds, diminished dorsalis pedis and posterior tibial pulses, client complaint of cramping pain in left foot. The nurse is doing what?

Clustering significant data cues.

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

Confirming a medical diagnosis

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 one 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 one month old infants

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.

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 12: Diagnosing, p. 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

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.

Deficient fluid volume

After a client suffers a myocardial infarction, the nurse formulates a possible nursing diagnosis of "Powerlessness." In order to determine the accuracy of the diagnosis, what would be the nurse's most appropriate action?

Discuss the client's health condition with the client.

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 loss of hair

Which of the following is classified as a nursing diagnosis?

Grieving

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 patient?

High Risk for Injury related to unsafe home environment

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

A nurse is interviewing an elderly 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

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?

Impaired physical mobility related to pain

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?

Impaired physical motility related to pain

A client is being admitted from the emergency room with complaints of shortness of breath, wheezing, and coughing. Which of the following would the nurse as an appropriate nursing diagnosis?

Ineffective airway clearance

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?

Ineffective health maintenance related to client's denial of illness

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

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?

Interview the client's family to assess the client's usual level of consciousness

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 patient problems that nurses can treat.

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

One major requirement of a nursing diagnosis is that it focuses on a problem that is

Legally treatable by registered nurses

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

A nurse suspects that a patient has a self-care deficit, but needs more data to confirm this diagnosis. What nursing diagnosis would the nurse write for this patient?

Possible

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.

An elderly 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

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?

Reporting signs and symptoms related to the client's kidney failure

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?

Risk for allergy response related to latex allergy

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?

Risk for community contamination related to possible environmental pollution

Which of the following statements 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 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 states, "I am sure the doctors have misdiagnosed me."

The nurse has identified a nursing diagnosis of "Risk for ineffective childbearing" 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 do not plan to tell my family about my pregnancy."

The nurse is caring for a client who was divorced from her spouse 2 weeks ago. The nurse identifies a possible nursing diagnosis of "Risk for loneliness." What assessment data would lead the nurse to revise the nursing diagnosis?

The client states, "I feel like I can finally get along with my life now that the divorce is final."

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 inserted her own beliefs into the interpretation of the data

The nurse has selected a nursing diagnosis of "Impaired home maintenance" for an elderly client. What assessment data would evidence this diagnosis?

The nurse observes unsafe conditions in the client's home.

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 determine the client's normal bowel elimination pattern.

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 client's reason for the client's refusal.

During a home health care visit, the nurse identifies a nursing diagnosis of "Caregiver role strain" for a parent who is caring for a ventilator dependent child. 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."

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.

Used legally inadvisable terms

Which of the following reflect the diagnosis stage? Select all that apply.

• "Based on what you have told me, it seems that urinary incontinence is a problem for you. What do you think?" • The nurse identifies that the client has effectively coped with health stressors in the past. • The nurse identifies that the client who is on strict bed rest is at risk for impaired skin integrity.

The nurse is aware that development of nursing diagnoses are:

both within the nursing scope of practice and are client focused.

A nurse is writing nursing diagnoses for patients on a busy hospital ward. Which nursing diagnoses are written correctly? (Select all that apply.)

• Deficient Fluid Volume related to abnormal fluid loss • Nutrition Deficit related to inability to eat a balanced diet

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

Which of the following are a correctly written three part nursing diagnoses? (Select all that apply.)

• Ineffective health maintenance related to lack of motivation as evidenced by client's statement of disinterest in improving health • Constipation related to side effects of antidepressants as evidenced by passage of hard, dry stool

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.

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."