Chapter 7 Study Set

Nursing Diagnosis

identification of an actual or potential health problem or life processes and responses to a problem. -in this step the nurse will make clinical judgments about a patients experiences and responses to problems or life events identified during the data collection process.

diagnosis label

identified from the North American diagnosis association international (NANDA-I) list of approved diagnostic statements.

Actual Nursing Diagnosis

identifies current problems or concerns a patient has.

Who's is the NANDA -I?

it approves nursing diagnostics labels. (north american nursing diagnosis association -international))

evidence-based practice

nursing care provided that is supported by sound scientific rationale -it helps the nurse through the nursing process for clinical judgment and inquiry during patient care.

When a nurse is making a diagnosis, does she use objective data, subjective data, or both?

objective and subjective data

Clustering

organizing patient assessment data into groupings with similar etiologies.

What are the components of health-promotion nursing diagnoses?

the diagnoses label and defining characteristics. Ex. "readiness for enhanced immunization status AEB/AMB expressed desire to identify provider os pneumonia vaccine

Nursing Diagnosis

the identification of actual or potential health problems or life processes and responses to a problem

What is the difference between medical and nursing diagnosis?

-Medical diagnoses identify & label medical illnesses (physical and psychological). -nursing diagnoses are broader in focus than a medical diagnosis. -nursing diagnosis consider a patients response to medical diagnoses and life situations while also making clinical judgments based on the patients actual medical diagnosis and condition.

8. What is NANDA and what is its role?

-NANDA is the North American Nursing Diagnosis Association. The are in charge of all written nursing diagnoses. -put taxonomy into place for nurses to use. Its a language -promotes evidence base research to validate diagnostic labels

diagnosis label

-a term or phrase that represents a pattern of related, clustered data. -first section of every nursing diagnosis -it describes the diagnostic focus and requires nursing judgment b/f its assignment to patient. -before assigning diagnostic label, nurse first checks with NANDA-I to make sure its an accurate diagnostic label.

identification of correct nursing diagnosis depends on what?

-acurate collection -validation -analysis -clustering patient data.

Risk Nursing Diagnosis

-applies when a patient could be at risk for additional health problems due to their crest disease. Ex. infection -all risk diagnoses start with "RISK FOR"

Actual Nursing Diagnosis

-describes the response of a patient to a current need, problem, or life processes. Ex. "acute pain (r/t) physical injury as evidence by (AEB/AMB) (1) complaint of pain at a level 8 on a scale of 0 -10 (2)fracture of the right femur (3) inability to move without grimacing and yelling.

Data Clustering

-organizing patient assessment data into groupings with similar underlying causes. -the nurse looks for cues among the data that support the diagnosis of a problem. -make sure to have all the information before clustering data. Ex. objective and subjective data related to mobility can be clustered.

How can you identify an accurate nursing diagnosis?

-requires analysis of assessment data and clustering of related cues and information. -this information includes: 1.objective & subjective information 2. info from interview of patient and family 3. laboratory and diagnostic test results 4. x rays 5.physician orders and documentation from health care provider.

When would a nurse use a health promotion nursing diagnosis?

-used in a situation when patients express interest in improving their health status through a positive change in behavior. used for patient improvement -all nurse health promotion diagnoses begin with "READINESS FOR ENHANCED"

Focusing on one problem at a time

-when writing a nursing diagnosis, the nurse should only use one label in the statement. incorrect: "Anxiety and Diarrhea related to" correct: "Anxiety related to" "Diarrhea related to"

7. How does a nursing diagnosis differ from a medical diagnosis?

.-Medical diagnoses identify and label medical(physical and psychological) illnesses. Nursing diagnoses consider a patient's response to medical diagnoses and life situations, in addition to making clinical judgments on the basis of a patient's actual medical diagnoses and conditions.

What are the three types of nursing diagnoses?

1. ACTUAL NURSING diagnoses identify existing problems or concerns of a patient. 2. RISK NURSING diagnoses apply when there is an increased potential or vulnerability for a patient to develop a problem or complication. 3. HeEALTH-PROMOTION nursing diagnoses are used in situations in which patients express interest in improving their health status through a positive change in behavior.

What are the 3 types of nursing diagnosis statements?

1. Actual nursing diagnoses 2. Risk Nursing Diagnosis 3. Health-promotion Nursing Diagnosis -each of these 3 diagnosis requires the nurses clinical judgment which is based on patient data, knowledge, and nursing experience

10. Identify the errors that the nurse should avoid when formulating nursing diagnose

1. clustering of unrelated data 2. accepting erroneous data 3. using medical diagnoses as related factors within the nursing diagnosis statement 4. missing the true underlying etiology of a problem 5. identifying multiple nursing diagnosis labels in one nursing diagnostic statement.

What are the parts of a nursing diagnosis

1. diagnosis label 2. related factors or risk factors 3. defining characteristics -however, they are written 2nd in a health-promoting nursing diagnosis.

What are the components of a written nursing diagnostic?

1. label 2. related factors 3. defining characteristics

Which steps are considered essential by the nurse for decision-making in a diagnostic process? Select all that apply. a. Data clustering b. Risk nursing diagnosis c. Formulating the diagnosis d. Identifying patient health problems e. Health promotion nursing diagnosis

A. Data clustering C.Formulating the diagnosis D. Identifying patient health problems

What care should the nurse take to prevent problems in the diagnostic process? Select all that apply. <p>What care should the nurse take to prevent problems in the diagnostic process? Select all that apply. a.Obtain extensive assessment data. b.Ensure assessment data are not missing. c.Collect accurate data and analyze them. d.Use medical diagnosis as the related factor. e.Consolidate all the concerns in a statement.

A. Obtain extensive assessment data b. ensure assessment data are not missing c. collect accurate data and analyze them

Your patient has been recently diagnosed with diabetes mellitus type 2. With no prior history in his family, he is unfamiliar with the diet and treatments. He will require an oral hypoglycemic medication, as well as information about the prescribed diet. He tells you, "I don't have any idea of what I will have to do." a. What are the key pieces of data in this patient's assessment? b. Identify at least one nursing diagnosis for this patient

A. The key pieces of data are recent diagnosis, no prior family history, unfamiliar with treatment regimen, and requires oral hypoglycemic and therapeutic diet. b. A nursing diagnosis for this patient can be: Knowledge deficit related to lack of exposure/unfamiliarity as evidenced by "I don't have any idea of what I will have to do."

What is an effective way of communicating patient status between nurses? <p>What is an effective way of communicating patient status between nurses? a. Formulate appropriate nursing diagnoses. b. Group pertinent patient-related data. c. Use nurse's notes during the assessment. d. Chat with other health care professionals.

A. formulate appropriate nursing diagnosis The nurse develops a nursing diagnosis to formulate patient goals. The nurse collects subjective and objective data and plans interventions to help the patient reach appropriate goals. Therefore, it is an effective way of communicating the patient's status to other nurses.

Which of the following actual nursing diagnoses best meets the criteria for a diagnostic statement? a. Impaired physical mobility R/T reduced range of motion as manifested by slow, unsteady gait. b. Excess fluid volume R/T loss of body weight. c. Risk for constipation R/T fluid intake and movement. d. Readiness for enhanced learning R/T knowledge deficit.

A. impaired physically R/T reduced range of motion

A nurse is designing a care plan for a patient who is experiencing dyspnea. Which components of the assessment data can be part of the risk nursing diagnosis for this patient? Select all that apply. <p>A nurse is designing a care plan for a patient who is experiencing dyspnea. Which components of the assessment data can be part of the risk nursing diagnosis for this patient? Select all that apply. a.Cyanosis b.The family history of the patient c.Reduced oxygen saturation of the blood d.Impaired gaseous exchange in the lungs Te.he diet that the patient should take in this disorder

A:Cyanosis C: reused O2 saturation of the blood D:impaired gaseous exchange in the lungs

risk factors

Are environmental, physiological, psychological, or situational concern that increases patients vulnerability to a POTENTIAL problem or concern.

11. For the label of Impaired Gas Exchange, indicate which defining characteristics are most appropriate to include in the diagnostic statement. Select all that apply. a. Emphysema b. Diminished lung sounds to R lower lung base c. Pulse oximetry of 89% d. Weight gain—5% in 2 weeks e. Pain in lower R leg on ambulation f. Crackles heard on auscultation

B. Diminished lung sounds to R lower lung base C.Pulse oximetry of 89% F. Crackles heard on auscultation

What is a nursing diagnosis? Select all that apply. a.The first step of the nursing process b.An analysis of the patient's assessment c.A determination based on a medical diagnosis d.The clustering of related assessment data e.A means of communicating the patient's needs

B. An analysis of the patient's assessment D. The clustering of related assessment data E. A means of communicating the patient's needs

What must the nurse do before writing a nursing diagnosis? Select all that apply. <p>What must the nurse do before writing a nursing diagnosis? Select all that apply a.Write a plan of care b.Cluster assessments c.Analyze assessments d.Identify the diagnosis label e.Make a medical judgment

B. Cluster assessment C. Analyze assessment D. Identify the diagnosis label The nurse gathers all the related assessments into clusters. The first section of the nursing diagnostic statement is the nursing diagnosis label. The nurse must be aware of the definition of the diagnosis label to be able to apply the accurate diagnosis label. The nurse identifies the accurate nursing diagnosis label based on knowledge of the definition of the diagnosis label.

A patient is anxious about an operation scheduled for the next day. The nurse identifies that the patient is anxious. Which interventions does the nurse use to decrease the patient's anxiety related to surgery? Select all that apply. a. Provide detailed instructions about discharge planning. b. Provide satisfactory answers to the patient's questions. c. Provide detailed instructions about the recovery process. d. Instruct the patient to perform range-of-motion exercises. e. Provide detailed instructions about the surgical procedure.

B. Provide satisfactory answers to the patient's questions. C. Provide detailed instructions about the recovery process. E. Provide detailed instructions about the surgical procedure.

A nurse is caring for a patient that has been admitted to the hospital with pneumonia. Which assessment findings of the patient can the nurse group together to formulate a data cluster? Select all that apply. <p>A nurse is caring for a patient that has been admitted to the hospital with pneumonia. Which assessment findings of the patient can the nurse group together to formulate a data cluster? Select all that apply. a. Dysuria b. Respiration 20 breaths/min c. Wheezing in left lung bases d. Weakness of the entire body e. Shortness of breath with ambulation

B. Respiration 2- breaths/ min C. wheezing in left lung bases e. shortness of breath with ambulation

The nurse is concerned that the patient has developed atelectasis following surgery. Which of the following is an appropriate diagnostic label for this problem? a.Ineffective airway clearance b. Impaired gas exchange c. Decreased cardiac output d. Impaired spontaneous ventilation

B. impaired gas exchange

The nurse assesses a patient and formulates a nursing diagnosis related to pain. Which patient data would support this diagnosis? a. The patient has an asthma exacerbation. b. The patient has monthly dysmenorrhea. c. The patient has lower-extremity edema. d. The patient has an elevated body temperature.

B. the patient has monthly dysmenorrhea -Dysmenorrhea means painful menstruation, which helps in formulating a nursing diagnosis related to pain.

Which of the following nursing diagnoses best meets the criteria for a diagnostic statement? a. Risk for diarrhea with the risk factor of the possible side effect of antibiotic therapy b. Risk for heart disease with the risk factor of smoking c. Risk for urinary retention following catheter removal d. Risk for pneumonia

B.risk for heart disease with the risk factor of smoking

For the patient with the nursing diagnosis of Activity Intolerance, the nurse expects that the patient will specifically demonstrate: a. elevated body temperature. b. disinterest in diversional activities. c. dyspnea on exertion. d. erythema.

C. Dyspnea on exertion

What does the nurse mention while writing the health-promotion nursing diagnosis? a. Diagnosis label and risk factors b. Diagnosis label and related factors c. Diagnosis label and defining characteristics d. Diagnosis label, related factors, and defining characteristics

C. diagnosis label and defining characteristics

15. For the nursing diagnosis, Altered speech related to recent neurological disturbances as evidenced by an inability to speak coherently, the etiology is: a. altered speech. b. as evidenced by. c. recent neurological disturbances. d. inability to speak coherently.

C. recent neurological disturbances

12. Nursing diagnoses are primarily used in order to: a. make all of the patient's problems easier to solve. b. assist the medical provider to determine care. c. meet accreditation requirements. d. facilitate clear communication of patient needs.

D. facilitate clear communication of patient needs

The nurse is caring for a patient with oropharyngeal dysphagia due to a neuromuscular disorder. What cause should the nurse identify when writing a nursing diagnosis? a. Acute pneumonia b. Difficulty swallowing c. Aspiration of liquid d. Neuromuscular impairment

D. neuromuscular impairment oropharyngeal dysphasia is difficulty swallowing

For the health-promotion nursing diagnosis of Readiness for enhanced nutrition, which of the following is the most appropriate defining characteristic? a. Inability to feed self b. Diminished oral intake c. Reduction in body mass and strength d. Identification of healthy food choice

D.Diminished oral intake

9. For the following patient information, identify how they may be clustered into a diagnostic label: • States, "I am very thirsty" • Reports weight loss of 5 lbs over the past 3 days • Complains of feeling tired • Has increased hematocrit and creatinine • Has decreased blood pressure with a slight increase in body temperature

Fluid volume, deficient

Taxonomy

a unified language classification system

taxonomy

a unified language system used among nurses and other healthcare professionals. -nursing diagnosis taxonomy can be applied to families, groups, individual, and communities.

cyanosis

bluish discoloration of the skin

A nurse reviews data gathered regarding a patient's pain symptoms. The nurse compares the defining characteristics for acute pain with those for chronic pain and in the end, selects acute pain as the correct diagnosis. This is an example of the nurse avoiding an error in: a. Data collection. b. Data clustering. c. Data interpretation. d. Making a diagnostic statement.

c. Data interpretation; because the nurse compares defining characteristics for the two nursing diagnoses and selects one based on the interpretation of data.

Etiology

cause of disease

Defining Characteristics

clustered supporting data.

defining characteristics

cues or clusters of related assessment data that are signs, symptoms, or indications of an actual or health-promotion nursing diagnosis

What are the components of risk nursing diagnoses?

diagnose label and risk factors Ex. Risk for Infection with the risk factor of a suppressed inflammatory response indicated by leukopenia.

Dyspnea

difficult or labored breathing

related factors

underlying cause or etiology of a patient's problem