Fundamentals of Nursing Chapter 12: Diagnosing

A nurse sees the client grimace and documents that the client is in pain, without interviewing the client to obtain further cues. The nurse has:

a lack of cues, or premature closure

In the development and documentation of a nursing diagnosis, the nurse should follow which of the following guidelines?

Accepted terms for nursing diagnoses may vary according to a school, employer, or specialty organization.

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

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

Bowel Incontinence

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

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 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 explaining the purpose of nursing diagnoses to a client. What would be the most appropriate statement for the nurse to make?

"Nursing diagnoses are used to guide the nurse in selecting appropriate nursing interventions."

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?

1

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

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 and her newborn, the nurse formulates a nursing diagnosis of "Risk for Impaired Attachment." 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

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.

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.

What does the nursing diagnosis represent?

Cues

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

While caring for a client admitted with clostridium difficile infection, the nurse notes that the client has had 3 loose bowel movements in 3 hours. What would be the most appropriate nursing diagnosis to address this health problem

Diarrhea related to infectious processes secondary to clostridium difficile infection as evidenced by 3 loose bowel movements in 3 hours

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

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."

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

Which of the following best defines nursing diagnoses?

Identification of client problems that nurses can treat independently

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

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 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 nursing diagnosis in the client's records?

Impaired physical mobility related to pain

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

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

A teenager on life support after a diving accident has no brain wave activity. The parents tell the nurse that they are sure their child will wake up soon. What nursing diagnosis would the nurse identify to assist the parents of the child?

Interrupted family processes related to inability to accept their child's inevitable death as evidenced by the parents' statement that their child will wake soon

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.

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

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.

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 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 client with diabetes mellitus has been admitted to the intensive care unit with a serum glucose reading of 400 mg/dl. Because the care for this client will involve multiple disciplines, what diagnostic statement would be most appropriate for the nurse to select?

PC: Hyperglycemia related to uncontrolled serum glucose

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

Which of the following nursing diagnoses is written incorrectly as a result of the health problem and etiology being reversed?

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.

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

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

When caring for a client, the nurse identifies and analyzes data to identify nursing diagnoses and collaborative problems. Which of the following is a priority role of the nurse when caring for a client with collaborative problems?

Reporting trends that suggest development of complications

Which of the following errors has the nurse made in formulating the following nursing diagnosis: 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.

Reversed the health problem and the etiology

The care plan for a post-surgical client includes a nursing diagnosis of "Risk for urinary retention." The nurse determines that the client has been voiding adequately. What is the nurse's most appropriate action?

Revise the nursing diagnosis because the client's status has changed.

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 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

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?

Risk for powerlessness

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?

Risk related to unknown outcome of surgery

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

The client has diminished breath sounds.

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."

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 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, what further step must the nurse take?

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

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 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

What information provides the nurse with accuracy when developing a nursing diagnosis?

a set of clinical cues

The nurse is aware that development of nursing diagnoses are:

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

The nursing diagnosis taxonomy provides nursing with:

common language.

A group of nursing students is reviewing information about nursing diagnoses. The students demonstrate understanding when they identify which as a characteristic feature?

describes the client's response to the health problem

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

legally treatable by registered nurses.

What is the purpose of establishing a nursing diagnosis?

to describe a functional health problem

Which of the following actions would take place during the diagnosis stage of the nursing process? 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 determines that the client needs to have a decrease in activity.

Nurses write various types of nursing diagnoses depending on the patient's condition. Which statements accurately describe types of NANDA nursing diagnoses? (Select all that apply.)

• A risk nursing diagnosis is a clinical judgment that an individual, family, or community is more likely to develop the problem than others in the same or similar situation. • An actual diagnosis represents a problem that has been validated by the presence of major defining characteristics. • A syndrome nursing diagnosis comprises a cluster of actual or risk nursing diagnoses that are predicted to be present because of certain events or situations.

While caring for a client admitted to the hospital for a fractured tibia, the nurse notes that the pattern of the client's blood pressure readings is consistently over the expected range for the client's age. How would the nurse most appropriately plan to care for this client?

• Address the collaborative problem PC: Hypertension.

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.

• Bowel Incontinence • Impaired Swallowing • Impaired Physical Mobility

What steps must the nurse take to assure accurate nursing diagnoses? (Select all that apply.)

• Collect complete and accurate data. • Ask the client to identify problems that concern the client. • Distinguish normal from abnormal data. • Select nursing diagnoses that address health problems that can be changed.

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

Which of the following are positive outcomes of the use of nursing diagnoses? (Select all that apply.)

• Encourages the client's participation in care • Improves communication between nurses • Directs areas of nursing research

The nurse is planning care for a client who has experienced a myocardial infarction. Which of the following would be appropriate nursing diagnoses for the nurse to select for this client? (Select all that apply.)

• Fear related to change in health status • Pain related to cardiac tissue damage

Which activities does the nurse perform during the diagnosing stage? Select all that apply.

• Identifies factors contributing to the client's health problem. • Prioritizes the client's health problems with input from the client. • Validates the identified health problems with the clients.

A student nurse is learning how to write a nursing diagnosis for a patient. Which actions are accurate guidelines when formulating nursing diagnoses? (Select all that apply.)

• Make sure the patient problem precedes the etiology. • Write the diagnosis in legally advisable terms. • Be sure the problem statement indicates what is unhealthy about the patient. • Make sure defining characteristics follow the etiology.

The nurse is responsible for recognizing significant data when developing nursing diagnoses. The following significant data would indicate a health problem may exist: (Select all that apply.)

• The client has a blood pressure reading of 150/90 mm Hg. • During assessment, the client is sweating and short of breath. • The client only answers yes or no questions.

A client has been admitted to a hospital, suffering from an acute psychotic episode. What assessment data would the nurse identify as client's strengths? (Select all that apply.)

• The client has ample financial resources. • The client is willing to attend counseling sessions.

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 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.

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."

The electronic health record enables the nurse to facilitate which nursing actions related to diagnosing? (Select all that apply.)

• Viewing the patient's ongoing risks • Deciding on and documenting new nursing diagnoses • Facilitating communication of the patient's actual problems • Making decisions about mutual patient goals and interventions • Determining and documenting when the nursing diagnoses are resolved

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 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)

• Wheezes auscultated over all lung fields • Labored respirations • Ineffective cough