CHAPTER 12 - NURSING PROCESS
What association meets every 2 years to further progress in defining, classifying, and describing nursing diagnoses? - The American Medical Association (AMA) - NANDA-International (NANDA-I) - The National League for Nursing (NLN) - The American Nurses Association (ANA)
NANDA-International (NANDA-I) Rationale: NANDA-International (NANDA-I) conferences are held every 2 years, and much progress continues to be made in defining, classifying, and describing nursing diagnoses.
The sclerae of a 3-day old infant have a yellowish tint and the nurse has just received an order to initiate phototherapy. Which nursing diagnosis will the nurse utilize to plan care for this client? - Neonatal Jaundice - Visual Deficit - Risk for Neonatal Jaundice - Risk for Visual Deficit
Neonatal Jaundice Rationale: The yellow color of the sclera indicates jaundice, which is a common problem in the neonatal period. It is related to difficulties in bilirubin conjugation. "Risk for neonatal jaundice" is inappropriate because the client is already jaundiced. Jaundice signals liver dysfunction, not any problems with vision.
Which example of client care is not the responsibility of the nurse? - promoting safety and preventing harm; detecting and controlling risks - tailoring treatment and medication regimens for each individual - monitoring for changes in health status - confirming a medical diagnosis
confirming a medical diagnosis Rationale: 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.
A student identifies Fatigue as a health problem and nursing diagnosis for a client receiving home care for treatment of metastatic cancer. What statement or question would be best to validate this client problem? - "Why are you so tired all the time?" - "I think fatigue is a problem for you. Do you agree?" - "I analyzed and interpreted your information as fatigue." - "I have assessed you and find you are fatigued."
- "I think fatigue is a problem for you. Do you agree?" Rationale: After a tentative nursing diagnosis is made, it should be validated. Clients who are able to participate in decision making should be encouraged to validate the diagnosis.
A nurse is formulating a nursing diagnosis for a client with a respiratory disease. Which nursing diagnosis would be correct? - "cough related to ineffective airway clearance" - "refuses to cough and expectorate thick mucus" - "ineffective airway clearance related to thick mucus" - "needs nasal oxygen to improve breathing"
- "ineffective airway clearance related to thick mucus" Rationale: It is important to use guidelines to formulate correctly written nursing diagnoses. The nurse would not use client needs, put defining characteristics before the diagnoses, or judge the willingness of the client to cough.
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 wellness diagnosis - A possible nursing diagnosis - A risk nursing diagnosis
- A wellness diagnosis Rationale: 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
A nurse has completed the client assessment and is now analyzing the data to determine specific client problems. The nurse identifies groups of data that deviate from the normal, putting all the pieces together to form a picture of the client. The nurse is engaged in which activity? - Premature closure - Cue clustering - Formation of cues - Cluster interpretation
- Cue clustering Rationale: Cue clustering refers to the grouping of cues (subjective and objective data) that deviate from standards or from what is considered normal. Cues are formed from the objective and subjective data gathered during the assessment. Premature closure refers to the selection of a nursing diagnosis before analyzing pertinent information, or developing a nursing diagnosis based on inadequate information. Cluster interpretation refers to synthesizing the cue clusters, which involves the nurse seeing the whole picture and attaching meaning to the cluster.
The nurse has drafted a nursing diagnosis of Imbalanced Nutrition: More Than Body Requirements in the care of a moderately obese client. How should the nurse proceed after writing this diagnosis? - Cross-reference the nursing diagnosis with medical diagnoses. - Modify interventions based on the diagnosis. - Identify potential complications. - Validate the nursing diagnosis
- Validate the nursing diagnosis Rationale: After writing a nursing diagnosis, it is important to verify and validate it. This action should precede the modification of the client's care. Nursing diagnoses do not always correlate with medical diagnoses and not every nursing diagnosis is accompanied by potential complications.
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 - 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 - Hopelessness related to inability to decide a course of action as evidenced by the client's statement
- Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement Rationale: 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.
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 Coping related to client's inability to manage the diabetic regimen - Risk for Unstable Blood Glucose related to client's reluctance to manage the diabetic regimen - Risk for Injury related to client's mismanagement of disease - Ineffective Health Maintenance related to client's denial of illness
- Ineffective Health Maintenance related to client's denial of illness Rationale: 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.
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? - Ineffective Airway Clearance related to bronchial constriction - Knowledge deficit: Medications related to new medical diagnosis - Anticipatory Grieving related to chronic illness management - Noncompliance related to deficient knowledge of a new medical diagnosis
- Knowledge deficit: Medications related to new medical diagnosis Rationale: 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 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. - Labored respirations - Wheezes auscultated over all lung fields - Oxygen at 3 liters/min per nasal cannula - Ineffective cough - Viral pneumonia
- Labored respirations - Wheezes auscultated over all lung fields - Ineffective cough Rationale: 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.
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? - Decrease stimulation and allow the client to rest. - Document the client's level of consciousness. - Consult with another nurse to validate the assessment. - Notify the physician for additional orders.
- Notify the physician for additional orders. Rationale: 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
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? - Collaborative problem - Medical diagnosis - Nursing assessment - Nursing diagnosis
- Nursing diagnosis Rationale: 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.
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: Fear related to new diagnosis of myocardial infarction - PC: Activity intolerance related to decreased oxygenation capacity
- PC: Decreased cardiac output related to cardiac tissue damage Rationale: 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
Which guideline is a correct one to follow when composing a nursing diagnosis statement? - Place defining characteristics after the etiology and link them by the phrase "as evidenced by." - Incorporate subjective and judgmental terminology. - Phrase the nursing diagnosis as a client need. - Place the etiology prior to the client problem and linked by the phrase "related to."
- Place defining characteristics after the etiology and link them by the phrase "as evidenced by." Rationale: Defining characteristics should follow the etiology and be linked by the phrase "as evidenced by" when included in the nursing diagnosis. The nursing diagnosis should be phrased as a client problem or alteration in health state, rather than as a client need. The client problem precedes the etiology and is linked by the phrase "related to." Avoid using judgmental language; write in legally advisable terms.
Which nursing diagnosis is an example of a wellness diagnosis? - Acute Pain - Readiness for Enhanced Parenting - Risk for Infection - Possible Chronic Low Self-Esteem
- Readiness for Enhanced Parenting Rationale: Wellness diagnoses are clinical judgments about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness. The diagnostic statement for a wellness diagnosis contains the label Readiness for Enhanced Parenting, followed by the desired higher-level wellness. Related factors are not included.
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 states, "I am sure the doctors have misdiagnosed me." - The client makes funeral plans. - 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." Rationale: 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 do not know how to take care of a baby." - 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 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." Rationale: 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.
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 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 inserted her own beliefs into the interpretation of the data. Rationale: 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.
Which actions would take place during the diagnosis stage of the nursing process? Select all that apply. - The nurse assists the client with ambulation to the bathroom. - The nurse identifies that the client has effectively coped with health stressors in the past. - "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 who is on strict bed rest is at risk for impaired skin integrity. - The nurse determines that the client needs to have a decrease in activity.
- The nurse identifies that the client has effectively coped with health stressors in the past. - "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 who is on strict bed rest is at risk for impaired skin integrity. - The nurse determines that the client needs to have a decrease in activity. Rationale: Diagnosing would include identifying the client's strengths (past effective coping) and potential health problems (risk for impaired skin integrity; risk for injury due to excessive activity) and validating the nursing diagnosis with the client (urinary incontinence). Assisting the client with ambulation would occur in the implementation stage.
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 attend support group meetings when I am able to go." - The parent states, "A member of my church gives me a break twice a week." - The parent states, "I make sure that I get regular exercise." - The parent states, "I cannot allow anyone else to help because they won't do it right."
- The parent states, "I cannot allow anyone else to help because they won't do it right." Rationale: The parent's statement of not allowing anyone to help because "they won't do it right" support's the nursing diagnosis of Caregiver Role Strain. The parent's statement indicates an inability to allow help, which will cause mental and physical strain. The other statements indicate a healthy ability to use coping mechanisms to deal with this difficult situation.
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. - cluster interpretation. - premature closure. - clustering of cues.
- premature closure. Rationale: 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.
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? - independently managing the client's kidney failure - coordinating the treatment of the client's kidney failure - reporting signs and symptoms related to the client's kidney failure - choosing interventions to resolve the client's kidney failure
- reporting signs and symptoms related to the client's kidney failure Rationale: In producing a nursing diagnosis, a nurse creates accountability for detecting and reporting the signs and symptoms of a medical diagnosis. The nurse is not legally responsible for independently managing or coordinating the client's treatment. Choosing and performing interventions to resolve the condition is primarily within the purview of the physician.
After completing assessments, a nurse uses the data collected to identify appropriate nursing diagnoses for a client. The nursing diagnoses are used to: - establish a database of information for future comparison. - evaluate the effectiveness of the established plan of care. - select nursing interventions to meet expected outcomes. - mutually establish desired outcomes of the plan of care.
- select nursing interventions to meet expected outcomes. Rationale: The nurse formulates, validates, and lists nursing diagnoses for each client. Nursing diagnoses provide the basis for selecting nursing interventions that will achieve valued client outcomes for which the nurse is responsible.
Which nursing diagnosis is validated by the presence of major defining characteristics? - Wellness diagnosis - Actual nursing diagnosis - Possible nursing diagnosis - Risk nursing diagnosis
Actual nursing diagnosis Rationale: Actual nursing diagnoses represent problems that have been validated by the presence of major defining characteristics. An actual nursing diagnosis has four components: label, definition, defining characteristics, and related factors.
"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 Rationale: 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.
A nurse is caring for an older adult client who is scheduled for a cystoscopy the next day to determine the cause of an overdistended bladder. The client informs the nurse that this the first time that she has been admitted to a health care facility for an illness. Which diagnostic label would the nurse use to formulate the nursing diagnosis? - Anxiety - Overdistention - Physical immobility - Compromised
Anxiety Rationale: Anxiety is an accurate diagnostic label, the name of the nursing diagnosis as listed in the taxonomy. Compromised is a descriptor; physical immobility is a risk factor; overdistension is a related factor.
A student is reviewing a client's chart before giving care. She notes the following diagnoses in the contents of the chart: "appendicitis" and "acute pain." Which of the diagnoses is a medical diagnosis? - Neither appendicitis nor acute pain - Acute pain - Appendicitis - Both appendicitis and acute pain
Appendicitis Rationale: Medical diagnoses identify diseases (in this case, appendicitis). Nursing diagnoses describe problems treated by the nurse within the scope of independent nursing practice.
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? - Homelessness Syndrome related to lack of housing as evidenced by visibly soiled clothing - Inadequate Hygiene related to homelessness as evidenced by client's stink - Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor 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 Impaired Impulse Rationale: 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.
A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination? - Bowel Incontinence - Irritable Bowel Syndrome - Small Bowel Obstruction - Ulcerative Colitis
Bowel Incontinence Rationale: 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 newly graduated nurse is unable to determine the significance of data obtained during an assessment. What would be the nurse's most appropriate action? - Continue to collect assessment data. - Contact the client's health care provider. - Document the data for future reference. - Consult with a more experienced nurse.
Consult with a more experienced nurse Rationale: 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
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? - Ineffective Health Maintenance related to being overwhelmed by cancer diagnosis - Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis - Knowledge Deficit: Cancer treatment options related to new diagnosis - Disturbed Self-Concept related to pancreatic cancer diagnosis
Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis Rationale: 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.
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 physical mobility related to pain - Ineffective physical mobility due to pain - Impaired movements due to pain
Impaired physical mobility related to pain Rationale: "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.
After assessing a client, the nurse formulates several nursing diagnoses. Which would the nurse identify as an actual nursing diagnosis? - Impaired urinary elimination - Readiness for enhanced sleep - Risk for infection - Possible impaired adjustment
Impaired urinary elimination Rationale: Impaired urinary elimination is an actual nursing diagnosis because it describes a human response to a health problem that is being manifested. Readiness for enhanced sleep is a wellness diagnosis. Risk for infection is a risk diagnosis, and possible impaired adjustment is a possible nursing diagnosis.
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 - Bronchial Pneumonia - Acute Dyspnea - Asthma Attack
Ineffective Airway Clearance Rationale: 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.
The formulation of nursing diagnoses is unique to the nursing profession. Which statement accurately represents a characteristic of diagnosing? - Nursing diagnoses remain the same for as long as the disease is present. - Nurses formulate nursing diagnoses to identify diseases. - Nursing diagnoses focus on identifying healthy responses to health and illness. - Nurses write nursing diagnoses to describe client problems that nurses can treat
Nurses write nursing diagnoses to describe client problems that nurses can treat Rationale: Data collection leads the nurse to identifying client problems that the nurse is able to treat with planned nursing interventions, which is the focus of nursing diagnoses. Nursing diagnoses change as client goals are met or as new problems develop. Medical diagnoses identify disease processes.
A nurse caring for an older adult client in a long-term care facility notices that the bedding is damp when the client gets up in the morning. The nurse suspects that the client has been incontinent of urine and collects more data to form a conclusion. What type of problem is involved in this scenario? - Clinical problem - Solvable problem - Possible problem - Actual problem
Possible problem Rationale: The nurse reaches one of four basic conclusions after interpreting and analyzing the client data: no problem, possible problem, actual or potential problem, or clinical problem. When dealing with a possible problem, the nurse must collect more data to confirm or disprove a suspected problem. There may or may not be a solution available once the problem is confirmed.
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 - Risk for Infection related to community contamination - 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 Rationale: 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 Pain After Surgery. - Risk for Falls related to altered mobility. - 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 Falls related to altered mobility Rationale: 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 of the following reflects the diagnosis phase? - The nurse identifies that the client does not tolerate activity. - The nurse documents the client's response to pain medication. - The nurse performs wound care using sterile technique. - The nurse sets a tolerable pain rating with the client.
The nurse identifies that the client does not tolerate activity Rationale: Recognition of a client health problem that can be prevented or resolved by independent nursing intervention, such as activity intolerance, is the focus of diagnosing. Performing wound care is an example of implementation. Setting a tolerable pain rating with the client is an example of planning. Documenting the client's response to pain medication is an example of evaluation.
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 bowel sounds. - The nurse should assess the client's dietary habits. - 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.
The nurse should determine the client's normal bowel elimination pattern. Rationale: 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.
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 client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping? - Risk Nursing Diagnosis - Wellness Diagnosis - Actual Nursing Diagnosis - Syndrome Nursing Diagnosis
Wellness Diagnosis Rationale: Readiness for Enhanced Coping is an example of a wellness diagnosis. Two cues must be present for a valid wellness diagnosis: a desire for a higher level of wellness and an effective present status or function. An actual nursing diagnosis represents a problem that has been validated by the presence of major defining characteristics. A risk nursing diagnosis is a clinical judgment that concludes that an individual, family, or community is more vulnerable to develop the problem than are others in the same or a similar situation. A syndrome nursing diagnosis comprises a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation.
A nurse formulates a nursing diagnosis of "constipation related to adverse effect of opioid analgesic as evidenced by no bowel movement in 4 days." The nurse identifies the defining characteristic as: - no bowel movement in 4 days. - opioid analgesic. - adverse effects of medication. - constipation.
no bowel movement in 4 days Rationale: The defining characteristics are the observable cues or inferences that cluster as manifestations, which in this case is the lack of a bowel movement in 4 days. Constipation is the diagnostic label. Adverse effect of the medication is the related factor. Opioid analgesic is part of the related factor
In addition to identifying responses to actual or potential health problems, what is another purpose of the diagnosing step in the nursing process? - to identify etiologies of health problems - to collect information about subjective and objective data - to evaluate mutually developed expected outcomes - to correlate nursing and medical diagnostic criteria
to identify etiologies of health problems Rationale: The purpose of diagnosing, the second step in the nursing process, is to identify how an individual, a group, or a community responds to actual or potential health and life processes; to identify etiologies (factors that contribute to or cause health problems); and to identify resources or strengths that the individual, group, or community can draw on to prevent or resolve problems.
