Lippincott for Taylor: Fundamentals of Nursing Chapter 15- Diagnosing

If a patient appears to meet a ______________, the nurse concludes that the patient has strength in that particular area, and this strength contributes to the patient's level of ________________

Standard; wellness

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

premature closure. Premature closure is when the nurse selects a nursing diagnosis before analyzing all of the pertinent information in the client's case. The nurse did not investigate any other information in this case before making a diagnosis. Inconsistent cues occur when the meaning attached to one cue may be altered based on another cue. The nurse in this case only considered one cue, so inconsistent cues could not be the correct answer. Clustering of cues is a clustering of data; this nurse has only one cue, so the nurse cannot cluster data or interpret data clusters.

How does a nursing diagnosis differ from a medical diagnosis?

A nursing diagnosis is an actual or potential health problem that an independent nursing intervention can resolve; Whereas a medical diagnosis is a statement about a specific disease process using terminology from a well-developed classification system

What is a primary distinction between a medical diagnosis versus a nursing diagnosis?

A medical diagnosis remains the same for as long as the disease is present, whereas a nursing diagnosis may change from day to day as the patient's responses change.

A client is caring for the client's mother in law, who is an older adult who requires assistance with performing activities of daily living. Which statement by the client would lead the nurse to make a nursing diagnosis of Caregiver Role Strain?

"I just don't have time to take a shower" The inability to care for oneself, such as not taking time for a shower, strongly indicates that this client is not coping well

What are the Diagnosing competencies of the registered nurse?

- Identifies actual or potential risks to the health care consumer's health and safety or barriers to health, which may include but are not limited to interpersonal, systemic, cultural, or environmental circumstances. -uses assessment data, standardized classification systems, technology, and clinical decision support tools to articulate actual or potential diagnoses, problems, and issues. -verifies the diagnoses, problems, and issues with the individual, family, group, community, population, and interprofessional colleagues. -prioritizes diagnoses, problems, and issues based on mutually established goals to meet the needs of the health care consumer across the health-illness continuum. -documents diagnoses, problems, and issues in a manner that facilitates the determination of the expected outcomes and plans.

What guidelines should a nurse follow to correctly diagnose health problems?

-Be familiar with nursing diagnoses and other health problems; read professional literature and keep reference guides handy. -Trust clinical experience and judgment, but be willing to ask for help when the situation demands more than your qualifications and experience can provide. -Respect your clinical intuition, but before writing a diagnosis without evidence, increase the frequency of your observations and continue to search for cues to verify your intuition. -Recognize personal biases and keep an open mind.

What are the nurse's responsibilities in diagnosing?

-Interpret & analyze patient data -Identify patient strengths & health problems -Formulate & validate nursing diagnoses -Develop a prioritized list of nursing diagnoses -Detect and refer signs & symptoms that may indicate a problem beyond the nurse's experience

After interpreting & analyzing patient data, the nurse reaches one of four basic conclusions:

-No problem -Possible problem -Actual or potential nursing diagnosis, problem, or issue -Clinical problem other than nursing diagnosis

What are the 3 types of NANDA nursing diagnoses?

-problem-focused -risk -health promotion

Predict, Prevent, Manage, and Promote (PPMP)

1) In the presence of known problems, predict the most common and most dangerous complications and take immediate action to (a) prevent them, and (b) manage them in case they cannot be prevented. 2) Whether problems are present or not, look for evidence of risk factors (things that evidence suggests contribute to health problems). If you identify risk factors, you aim to reduce or control them, thereby preventing the problems themselves. 3) In all situations, ensure that safety and learning needs are met, and promote optimum function and independence.

Guidelines for writing a nursing diagnosis include:

1) Phrase the nursing diagnosis (DX) as a patient problem or alteration in health state rather than as a patient need. 2) Check to make sure that the patient problem precedes the etiology and that the two are linked by the phrase "related to" (R/T). 3) Consider when at-risk populations or associated conditions should be identified. 4) Defining characteristics, when included in the nursing diagnosis, should follow the etiology and be linked by the phrase "as manifested by" or "as evidenced by" (AEB). 5) Write in legally advisable terms. 6) Use nonjudgmental language. 7)Be sure the problem statement indicates what is unhealthy about the patient or what the patient wants to change (enhance). 8) Avoid using defining characteristics, medical diagnoses, or something that cannot be changed in the problem statement. 9) Reread the diagnosis to make sure that the problem statement suggests patient outcomes and that the etiology will direct the selection of nursing measures.

What are the purposes of diagnosing?

1) to identify how an individual, group or community responds to actual or potential health and life processes 2) to identify factors that contribute to or cause health problems 3) to identify resources or strengths that the person, group, or community can draw on to prevent or resolve problems

Which information ensures accuracy when the nurse is developing a nursing diagnosis? Abnormal diagnostic test results Specific nursing interventions A set of lab values A cluster of clinical cues

A cluster of clinical cues Each piece of client information is considered a clinical cue; a set of clinical cues that all suggest the same problem form a cue cluster. Basing a nursing diagnosis on a cluster of cues rather than a single cue improves the accuracy of the nursing diagnosis. Lab values or abnormal diagnostic test results along would not be as likely to improve accuracy as a cluster of related cues. The nurse would develop specific nursing interventions during the planning phase of the nursing process, immediately after the diagnosing phase.

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 possible nursing diagnosis A health promotion nursing diagnosis A problem-focused nursing diagnosis A risk nursing diagnosis

A risk nursing diagnosis Because the nurse is trying to address health problems that the client is at risk for because of obesity, the appropriate diagnosis is a risk nursing diagnosis. The nurse is not addressing a health problem that the client has or a health problem that the nurse needs more information to validate, so a problem-focused or possible nursing diagnosis is not appropriate. The client is not seeking health information, so a health promotion diagnosis is inappropriate.

Why is reporting all abnormal data significant in identifying potential complications?

Abnormal data may be indicative of serious or life-threatening complications

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

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

"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? Potential nursing diagnosis Health promotion nursing diagnosis Actual nursing diagnosis Risk nursing diagnosis

Actual nursing diagnosis This is an actual nursing diagnosis as it contains the diagnostic label (acute pain), related factors (instillation of peritoneal dialysate), and defining characteristics (wincing, grimacing during procedure, stabbing sensation).

"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? Potential nursing diagnosis Health promotion nursing diagnosis Actual nursing diagnosis Risk nursing diagnosis

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

What is a collaborative problem?

Actual or potential health problem that may occur from complications of disease, diagnostic studies, or the treatment regimen; the nurse works together with other members of the health care team toward its resolution

The nurse recognizes that health problems that the nurse can address by independent nursing interventions are called: Collaborative nursing diagnoses Actual or potential nursing diagnoses Dependent nursing diagnoses Syndrome nursing diagnoses

Actual or potential nursing diagnoses

A 19-year-old college basketball player is being evaluated for injuries after a skiing accident. The nurse determines that the client has a pulse of 52 beats/min. What would be the most appropriate way for the nurse to determine the significance of the client's heart rate? Compare the client's heart rate to that another adolescent client. Have another nurse reassess the heart rate for accuracy. Ask the client whether the heart rate is normal for the client. Determine whether the client has any risk factors for cardiac disease.

Ask the client whether the heart rate is normal for the client. A well-conditioned athlete is very likely to have a pulse rate lower than normal at rest. The key assessment is to compare the current heart rate with the client's baseline. Asking the client would be a simple way of confirming it. Comparing the client's heart rate with that of another adolescent client does not take into account the individual differences of clients. If a nurse is competent in physical assessment, there is no need to have another nurse check the heart rate. The pulse rate of 52 beats/min does not indicate any risk for cardiac disease. The client is also being seen in the emergency room for an urgent health problem. This assessment can wait until later.

When planning initial care for a 16-year-old client and the client's newborn, the nurse formulates a nursing diagnosis of "Risk for Impaired Attachment." What would be the nurse's most appropriate action to take next? Direct all education of infant care to the client's mother. Assess the client's interactions with the newborn. Develop a comprehensive education plan for infant care. Initiate referrals to available community services.

Assess the client's interactions with the newborn. To address a risk nursing diagnosis, the nurse is required to collect additional data. Observing the client's interactions with the newborn would be the most effective way to evaluate attachment. It is inappropriate to assume that the client's mother will be doing all the infant care, which would also be detrimental to the client's attachment to the infant. It is premature to initiate referrals to community services until further data are collected. It is also premature to develop a comprehensive education plan until the needs of the client are known.

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

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

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

Bowel Incontinence Impaired Swallowing Impaired Physical Mobility Bowel Incontinence, Impaired Swallowing, and Impaired Physical Mobility are all health problems that provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. Dysphagia and hemiparesis are medical diagnoses.

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

Bowel incontinence

A nurse has selected a nursing diagnosis and is preparing to validate it. With whom would the nurse do this? Another staff nurse Client The unit's nurse manager Client's health care provider

Client After selecting a nursing diagnosis, the nurse should validate it with the client. Validation legitimizes the diagnosis and helps to discover its significance for the client. -There is no need to validate the nursing diagnosis with another staff nurse, the client's health care provider, or the unit's nurse manager.

Cues that all relate to the same client problem may be grouped together in a process known as: clustering. categorizing. diagnosing. grouping.

Clustering Cue clustering brings together cues that if viewed separately would not convey the same meaning. The cues are not being categorized or diagnosed. Grouping is not proper terminology.

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 reports cramping pain in left foot. The nurse is doing what? Clustering significant data cues Identifying contributing factors Validating the nursing diagnosis Formulating a nursing diagnosis

Clustering significant data cues Data clustering involves grouping client data or cues that point to the existence of a client health problem. When formulating a nursing diagnosis, the nurse identifies the client health problem related to an etiology and includes subjective and objective data that support the existence of the actual or potential health problem. The nurse identifies contributing factors in the etiology portion of the nursing diagnosis. The nurse validates the nursing diagnosis, often with the client, after a tentative one is formulated.

Which type of health problem requires both health care provider- and nurse-prescribed actions to address?

Collaborative health problem

While developing a plan of care for a client, what should the nurse do before selecting a nursing diagnosis? Establish short- and long-term client goals. Perform a focused assessment related to the reason for admission. Collect client subjective and objective data. Verify the primary care provider's written orders.

Collect client subjective and objective data. Nursing diagnoses are developed as the second step of the nursing process. The first step is to collect all assessment data so that appropriate actual or potential nursing problems can be selected and addressed in the client's plan of care. -Nursing diagnoses are not related to the medical diagnosis or the specific written orders from the primary care provider. Goals can only be established after the problem is identified. Although assessment--collecting subjective and objective client data--is necessary before developing nursing diagnoses, this assessment does not necessarily have to be a focused assessment.

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

Confirming a medical diagnosis

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

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

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

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

A nurse in the emergency room, who is unfamiliar with pediatric clients, assesses the vital signs of a 1-month old infant with a heart rate of 124 and a respiratory rate of 36. What would be the most appropriate measure for the nurse to take to analyze the significance of the infant's vital signs? Ask the mother if the infant's heart rate is higher than normal. Report the vital signs and allow the emergency room health care provider to determine the significance. Perform a complete physical assessment to determine the cause of the elevated vital signs. Consult reference materials to determine the normal vital signs for 1-month old infants.

Consult reference materials to determine the normal vital signs for 1-month old infants. It is part of nursing practice to interpret the significance of assessment data by comparing it to standards. The nurse should consult reference materials to determine the normal range of vital signs for this client. Deferring to the emergency room health care provider is unprofessional and may result in harm to the client. Asking the mother if the infant's vital signs are higher than normal is unprofessional practice. A complete physical assessment is not necessary at this time.

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

The term _________ is often used to denote significant data or data that influences an analysis

Cue

Which component of a nursing diagnosis gives additional meaning to the nursing diagnosis?

Descriptors

The nurse is systematically gathering & clustering data to draw inferences regarding a newly admitted client's health problems. This process is best identified as which?

Diagnostic reasoning- Diagnostic reasoning is the process of gathering and clustering data to draw inferences regarding clients health problems and to propose diagnoses

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

Diarrhea related to infectious process as evidenced by 3 loose bowel movements in 3 hours

While caring for a client admitted with a Clostridium difficile infection, the nurse notes that the client has had three loose bowel movements in 3 hours. What would be the most appropriate nursing diagnosis to address this health problem? Diarrhea related to infectious process as evidenced by three loose bowel movements in 3 hours Risk for Injury related to urgent need for bowel evacuation Fluid Volume Excess related to diarrhea as evidenced by three loose bowel movements in 3 hours Risk for Infection Transmission related to high potential for communicability

Diarrhea related to infectious process as evidenced by three loose bowel movements in 3 hours The assessment data point to the diagnosis of diarrhea. The other three diagnoses may be part of the care plan for C. difficile, but the assessment data do not provide evidence for the other diagnoses. The client would be at greater risk for a fluid volume deficit rather than a fluid volume excess.

The nurse is assessing a client who was just admitted to the unit following an abdominal hysterectomy. On which assessment finding would the nurse base the priority diagnosis? Skin warm and dry Client reports being very sleepy Diminished breath sounds in left lower lobe Dressing intact with slight bloody discharge present Abdominal area soft with diminished bowel sounds throughout

Diminished breath sounds in left lower lobe Abnormal respiratory findings are a priority in the postoperative client. Slight discharge on the abdominal dressing may be expected but should be noted and observed for further bleeding. Being sleepy following anesthesia is a normal finding. Warm and dry skin is a normal finding.

A client undergoing chemotherapy for breast cancer has lost all 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 Disturbed Body Image as evidenced by client's refusal to look at self Disturbed Body Image as evidenced by client's negative comments Disturbed Body Image related to breast cancer

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

Why does etiology direct nursing intervention?

Etiology identifies factors that maintain the unhealthy patient state and prevent the desired change

The nurse is planning care for a client who has experienced a myocardial infarction. Which would likely be appropriate nursing diagnoses for the nurse to select for this client? Select all that apply. Pain related to cardiac tissue damage Pulmonary Edema Fear related to change in health status Determine Cardiac Function Abnormal Cardiac Rhythm

Fear related to change in health status Pain related to cardiac tissue damage Fear and pain are appropriate nursing diagnoses, because they can be addressed by nursing care. Abnormal cardiac rhythm is an etiology for myocardial infarction. Pulmonary edema is a medical diagnosis. Determining cardiac function is the health care provider's domain.

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 Disturbed Self-Concept related to pancreatic cancer diagnosis Knowledge Deficit: Cancer treatment options related to new diagnosis

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

Which assessment findings would support the nursing diagnosis of Impaired Skin Integrity? Select all that apply. History of appendectomy Up with assistance to bedside commode Unable to turn in bed without assistance Uncontrolled diabetes Impaired mobility due to recent stroke

Impaired mobility due to recent stroke Unable to turn in bed without assistance Uncontrolled diabetes Diabetes, impaired mobility, and needing assistance to turn in bed increase the risk of skin breakdown. A past surgical history would not contribute to the diagnosis. Increasing mobility by moving the client to the bedside commode would lessen the chance for skin breakdown.

When developing nursing diagnoses, the nurse should focus on which area? Problem validation through health care provider collaboration Human responses to actual or potential health problems Pathophysiological responses occurring in body systems Actions to be initiated for treatment

Human responses to actual or potential health problems The main focus of nursing diagnoses is on monitoring human responses to actual or potential health problems, whereas the main focus of medical diagnoses and collaborative problems is on monitoring the pathophysiological responses of body organs or systems. Actions to be initiated for treatment are the main focus for interventions or treatment. Collaboration with the health care provider to validate the problem reflects medical diagnoses or collaborative problems.

Which activities does the nurse perform during the diagnosing stage? Select all that apply. Prioritize the client's health problems with input from the client. Identify factors contributing to the client's health problem. Establish plan priorities with the client and family. Validate the identified health problems with the clients. Collect data to monitor quality and effectiveness of nursing practice.

Identify factors contributing to the client's health problem. Prioritize the client's health problems with input from the client. Validate the identified health problems with the clients. During the diagnosis stage, the nurse identifies factors contributing to the client's health problem, validates the identified health problems with the client, and prioritizes the client's health problems with input from the client. The nurse establishes plan priorities with the client and family during the outcome identification and planning. The nurse collects data to monitor the quality and effectiveness of nursing practice during the evaluation stage.

When developing a nursing diagnosis for a client, which should the nurse do first? Identify the significant data Group cues together to form a meaningful cluster Validate nursing diagnosis with the client Interpret the clustered data

Identify the significant data

When developing a nursing diagnosis for a client, which should the nurse do first? Synthesize cue clusters Identify the significant data Validate the diagnosis Cluster the cues

Identify the significant data The first step in developing a nursing diagnosis is to look at the data for significant cues. After identifying significant data or cues, the nurse then groups the cues together to form meaningful clusters that describe specific client problems. Cluster interpretation involves synthesizing the cue clusters, to see the whole picture and attach meaning to the cluster. After developing the nursing diagnosis, the nurse should validate it with the client.

Which would be an appropriate nursing diagnosis for a client with cachexia and decreased weight? Lack of Adequate Nutrition Weight Loss Imbalanced Nutrition: Less than Body Requirements Anorexia Nervosa

Imbalanced Nutrition: Less than Body Requirements The most appropriate nursing diagnosis would be Imbalanced Nutrition: Less than Body Requirements. -Anorexia Nervosa is a medical diagnosis. Lack of Adequate Nutrition and Weight Loss are not standard terminology for nursing diagnoses.

A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain, which is interfering with the client's ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records? Ineffective Movement related to arthritis Ineffective Physical Mobility due to pain Impaired Physical Mobility related to pain Impaired Movements due to pain

Impaired Physical Mobility related to pain "Impaired Physical Mobility related to pain" is the correct nursing diagnosis because it consists of an accurate descriptor, diagnostic label, and related factor. "Ineffective Movement related to arthritis" is an incorrect entry because the descriptor is incorrect and the diagnostic label is not approved. "Impaired Movements 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.

A nurse, who is caring for a client admitted to the patient care unit with acute abdominal pain, formulates the care plan for the client. Which nursing diagnosis is the priority for this client? Impaired Comfort Disturbed Body Image Disturbed Sleep Pattern Activity Intolerance

Impaired comfort Acute pain in the abdomen disturbs all the systems of the body. Relieving the pain should be the nurse's first priority. According to Maslow, physiologic needs are the highest priority. The client may have Disturbed Body Image, Disturbed Sleep Pattern, or Activity Intolerance, but all these are secondary to pain.

The client is admitted to the surgical unit following an exploratory laparotomy. Which nursing diagnosis is the priority? Deficient knowledge Risk for imbalanced body temperature Impaired skin integrity Fear/anxiety

Impaired skin integrity The priority nursing diagnosis is impaired skin integrity. The skin is the body's first line of defense against infection and the surgical incision impairs skin integrity, increasing the risk for infection. Deficient knowledge requires teaching, and during the early postoperative period, most clients will not be in a condition to accept teaching. Actual diagnoses are a priority over "risk for" diagnoses. Fear and anxiety cannot be addressed until basic physiologic needs are met.

What is the primary patient benefit from nursing diagnoses?

Individualization of nursing care, enabling nurses to direct their energy toward differing patient priorities

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

Ineffective Airway Clearance Because 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.

Which is the best example of a nursing diagnosis? Ineffective Breastfeeding related to latching as evidenced by nonsustained suckling at the breast. Ineffective Airway Clearance as evidenced by client not speaking. Cellulitis related to infection as evidenced by warm, reddened skin. Gastroesophageal Reflux related to low stomach pH as evidenced by foul breath and burning sensation in throat.

Ineffective Breastfeeding related to latching as evidenced by nonsustained suckling at the breast. Ineffective breastfeeding contains all the correct and necessary components of a nursing diagnosis. Both Gastroesophageal Reflux and Cellulitis are medical diagnoses. Ineffective Airway Clearance is an appropriate diagnostic label. However, a client not speaking does not match the 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? Risk for Unstable Blood Glucose related to client's reluctance to manage the diabetic regimen Ineffective Health Maintenance related to client's denial of illness Ineffective Coping related to client's inability 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 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 denies 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 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

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 Viral pneumonia Oxygen at 3 L/min per nasal cannula Ineffective cough Wheezes auscultated over all lung fields

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

The nurse is caring for a client with AIDS who frequently misses clinic appointments. The client states that transportation to the clinic is very difficult. What would be an appropriate diagnosis?

Ineffective health maintenance related to transportation difficulties

An adolescent on life support after a diving accident has no brain wave activity. The parents tell the nurse they are sure their child will wake up soon. Which nursing diagnosis would the nurse identify to assist the parents of the child? Death Anxiety related to anticipated death of child as evidenced by child having no brain wave activity Death Anxiety related to dysfunctional family processes as evidenced by parents' refusal to acknowledge the child's condition Interrupted Family Processes related to brain death of their child as evidenced by parents' refusal to accept the inevitable 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

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 parents of the adolescent verbalize a denial of their child's condition by their statement. They are unable to accept their child's death and the normal family processes of beginning that acceptance. Brain death of the child cannot be changed, so it is an unacceptable etiology. Death anxiety is an inappropriate nursing diagnosis because the diagnosis refers to anxiety over death of self.

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

Interview the client's family to assess the client's usual level of cognition. To properly analyze the assessment data, the nurse must compare them against the client's normal or baseline data. The family is the best informant for a client with cognitive impairment. -The medical diagnosis is not necessary to determine whether the client's condition is abnormal for the client. -The nurse should obtain the vital signs, but doing so will not give an indication of the client's usual level of cognition. -Ensuring the client's safety is an important nursing intervention but will not assist in analyzing these data.

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? 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 Ineffective Airway Clearance related to bronchial constriction

Knowledge Deficit: Medications related to new medical diagnosis To most appropriately address the client's health problem, the nurse should educate the client about the new medications the health care provider 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.

Although defining characteristics are written __________ in a nursing diagnosis, they should be considered ________________

Last; First

Which are accurate guidelines when formulating nursing diagnoses? Select all that apply. Write the diagnosis in legally advisable terms. Be sure the problem statement indicates what is unhealthy about the client. Make sure defining characteristics follow the etiology. Include the medical diagnosis in the nursing diagnosis. Phrase the nursing diagnosis as a client need rather than an alteration. Make sure the client problem precedes the etiology.

Make sure the client problem precedes the etiology. Write the diagnosis in legally advisable terms. Be sure the problem statement indicates what is unhealthy about the client. Make sure defining characteristics follow the etiology. The etiology is the cause of the client problem; therefore, the nursing diagnosis precedes the etiology. The nurse should write the nursing diagnosis in legally advisable terms. The problem statement, which is the nursing diagnosis, indicates what is wrong with the client. Defining characteristics support the nursing diagnosis and should follow the etiology to show support for the nursing diagnosis. -A medical diagnosis is only made by a primary care provider and should not be included in the nursing diagnosis because the nurse cannot prescribe treatment for a medical diagnosis. -The nursing diagnosis is the identification of a client alteration or problem, not a need.

It's important to remember that nursing diagnoses are NOT ______________ diagnosis or statements of patient ___________________

Medical; Need

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 should the nurse use to plan care for this client? Risk for Visual Deficit Neonatal Jaundice Visual Deficit Risk for Neonatal Jaundice

Neonatal Jaundice 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.

What does NANDA stand for?

North American Nursing Diagnosis Association

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? Document the level of consciousness Notify the provider for additional orders Validate the assessment with another nurse Decrease stimulation and allow the client to rest

Notify the health care provider for additional orders The client's decreased level of consciousness could indicate that the client is developing an electrolyte imbalance. The change in the client's status requires notification of the health care provider. Medication orders are required to treat the electrolyte imbalance.

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 health care provider for additional orders. Consult with another nurse to validate the assessment. Decrease stimulation and allow the client to rest. Document the client's level of consciousness.

Notify the health care provider for additional orders. The client's decreased level of consciousness could indicate that the client is developing an electrolyte imbalance. The change in the client's status requires notification of the health care provider. 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.

Who has the primary responsibility for collaborative problems?

Nurses

____________________________ provide the basis for selecting nursing interventions that will achieve valued patient outcomes for which the nurse is responsible

Nursing diagnoses

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

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

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

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

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

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

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? Wound Infection related to infectious processes Infection as evidenced by redness, edema, and warmth at the surgical site PC: Infection related to disrupted skin integrity secondary to abdominal surgery Risk for Infection related to a disruption of skin integrity secondary to abdominal surgery to be treated by an antibiotic

PC: Infection related to disrupted skin integrity secondary to abdominal surgery When the client is at risk for infection, nurses can care for the client with independent nursing interventions. Once the client becomes infected, the client will need an antibiotic, which the health care provider must prescribe and which necessitates a collaborative diagnosis. The nursing diagnosis never addresses prescribed medication. Nurses do not formulate medical diagnoses. Actual infection is no longer an independent nursing problem.

Why should nursing diagnoses always be derived from clusters of significant data versus a single cue?

Patient symptoms may be misinterpreted from a single cue; whereas clusters of data highlight emerging patterns

The best use of nursing diagnosis is in partnership with whom?

Patients, families, groups, and communities

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

Possible Possible nursing diagnoses are statements describing a suspected problem for which additional data are needed. Additional data are used to confirm or rule out the suspected problem. An actual nursing diagnosis means that there is data to support a client's actual health care problem. NANDA-I describes five types of nursing diagnoses: actual, risk, possible, health promotion, and syndrome.

Which nursing diagnosis is written incorrectly as a result of the health problem and etiology being reversed? Pain related to tissue trauma and inflammation Risk for Injury related to lack of knowledge of crutch walking Prolonged Immobility related to impaired skin integrity Risk for Disturbed Body Image related to decreased ability to cope with surgical removal of right breast

Prolonged Immobility related to impaired skin integrity

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? Ineffective Health Maintenance related to lack of knowledge of childhood immunizations Risk for Infection Transmission related to lack of immunizations Risk for Complications related to childhood illnesses Readiness for Enhanced Knowledge: Childhood Immunizations

Readiness for Enhanced Knowledge: Childhood Immunizations The community group is asking for information to enhance their health care habits. A health promotion diagnosis of Readiness for Enhanced Knowledge is indicated. -There is no evidence of ineffective health maintenance practices. -There is no evidence that the clients lack immunizations. -Risk for Complications might result from a lack of immunizations, but that is not the issue being addressed here.

Which is a legal responsibility of a nurse who has documented a nursing diagnosis related to a 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 Independently managing the client's kidney failure

Reporting signs and symptoms related to the client's kidney failure 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 health care provider.

Which action is a priority role of the nurse when caring for a client with collaborative problems?

Reporting trends that suggest the development of complications

Which error has the nurse made in formulating the following nursing diagnosis: Prolonged Immobility related to impaired skin integrity as evidenced by an open area with a 1-inch diameter on the right buttocks surrounded by a 1-inch margin of redness; wound surface clean and beefy red; no drainage or foul odor detected. Omitted the defining characteristics of the client health problem Reversed the health problem and the etiology Identified environmental factors rather than client factors as the problem Wrote the diagnosis in terms of a need rather than a client response

Reversed the health problem and the etiology The nurse has reversed the health problem and etiology. Impaired Skin Integrity related to prolonged immobility is the correct format. The nursing diagnosis does address a client response rather than need: impaired skin integrity as a response to prolonged immobility. The nursing diagnosis does include defining characteristics: open area on the buttocks, wound surface clean and beefy red, no drainage or foul odor. The nursing diagnosis does not refer to environmental factors.

Which is an accurately phrased risk nursing diagnosis? Risk for Pain After Surgery 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 Risk for Impaired Coping as evidenced by client crying

Risk for Falls related to altered mobility Risk for Falls related to altered mobility is an accurately phrased risk nursing diagnosis. It is a two-part statement that contains the diagnostic statement (Risk for Falls) and risk factors (altered mobility). -Two of the options (Risk for Impaired Coping and Risk for Fluid Volume Excess) incorrectly pair actual presenting manifestations, also called defining characteristics (client crying, consuming 3 L of soda), with a risk statement. -Another option (Risk for Pain After Surgery) does not include a risk factor.

An older adult client's venous ulcer has become foul-smelling after the client began using strips of a sheet to dress the wound due to running out of sterile dressing supplies. How should the nurse document a nursing diagnosis statement related to this client's circumstances? Acute Confusion related to appropriate wound care Risk for sepsis related to local infection. Risk for Infection related to knowledge deficit Knowledge Deficit due to risk for infection

Risk for Infection related to knowledge deficit Risk for Infection related to knowledge deficit is the correct answer. The client's use of nonsterile items to dress a wound clearly indicates a lack of knowledge. Acute confusion describes a change in cognition, not an inappropriate action. A risk for infection does not cause a knowledge deficit. Indeed sepsis can result from an infection, but infection is a medical diagnosis, not a nursing diagnosis.

Which nursing diagnosis has the priority when caring for an older adult client with Alzheimer disease? Self-Care Deficit Impaired Memory Impaired Physical Mobility Risk for Injury

Risk for Injury Clients with Alzheimer disease are highly prone to injuries. Risk of Injury may also be precipitated by the altered memory. Mortality and morbidity resulting from injury is highest in older age groups. Consequently, it is very important for the nurse to provide a safe and secure environment. Impaired Physical Mobility, Self-Care Deficit, and Impaired Memory are also present but are not the highest priority.

Which statement appropriately identifies a risk nursing diagnosis for a client who is confined to bed?

Risk for impaired skin integrity related to bed rest

Which assessment findings would support the nursing diagnosis of Acute Pain? Select all that apply. The client is a heavy cigarette smoker. The client had an abdominal hysterectomy 1 day ago. The client is crying in pain about 20 minutes before pain medicine is due. The client has a history of osteoarthritis. The client had back surgery 2 years ago and expresses the need for ibuprofen on most days.

The client had an abdominal hysterectomy 1 day ago. The client is crying in pain about 20 minutes before pain medicine is due. The client crying in pain or recovering from surgery 1 day ago would warrant a nursing diagnosis of Acute Pain. Pain that a client might be experiencing from past back surgery would be chronic and would not support the diagnosis of Acute Pain. Just because a client has a history of a painful condition, such as osteoarthritis, does not mean that the client is currently in acute pain. Being a heavy smoker does not support the diagnosis of Acute Pain.

A client has been admitted to a hospital due to an acute psychotic episode. Which assessment data would the nurse identify as this client's strengths? Select all that apply. The client is willing to attend counseling sessions. The client refuses to take the ordered medication. The client is male and 35 years old. The client has been living on the street for 3 weeks. The client has ample financial resources.

The client has ample financial resources. The client is willing to attend counseling sessions. The client's financial resources and willingness to attend counseling will be positive factors in the client's recovery. The lack of a stable living environment would lessen the chance for compliance with the health care regimen once discharged. The client's refusal to take medication would not allow the health care providers to implement an important part of this client's treatment. That the client is male and 35 years old is neither a strength nor a weakness.

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

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

A nursing diagnosis of "Complicated Grieving" has been identified for a client whose spouse died 1 year ago. What assessment data would be appropriate evidence to justify this diagnosis? Select all that apply. The client states, "I miss my wife every day." The client attempted suicide 1 month ago. The client states, "I have no interest in doing anything." The client keeps a picture of the client's wife at the bedside. The client no longer indulges in usual activities.

The client no longer indulges in usual activities. The client attempted suicide 1 month ago. The client states, "I have no interest in doing anything." Still grieving the loss of a spouse after 1 year is a normal manifestation of grief. Keeping a picture of the spouse is also normal. No longer indulging in usual activities, attempting suicide, and stating that one has no interest in doing anything are signs of depression and unresolved grief.

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 has difficulty concentrating on the details of treatment options. The client reports an inability to get adequate restful sleep. The client requests the minister of the client's church to visit. The client states, "I can't handle all of this." The client asks for information relating to the cancer diagnosis.

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." Inability to sleep, difficulty concentrating, and the client's verbalization of being overwhelmed are evidence of inability to cope. Seeking information related to the diagnosis and seeking out a spiritual adviser are positive ways of coping.

The nurse has been providing care to a client during a divorce. The client is now divorced from the spouse, effective 2 weeks ago. The nurse identified a nursing diagnosis of "Readiness for Enhanced Coping." What statement by the client would support this nursing diagnosis?

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

During a home health care visit, the nurse identifies a nursing diagnosis of Caregiver Role Strain for a parent who is caring for a child dependent on a ventilator. What subjective assessment data would support the nurse's diagnosis? The parent states, "I cannot allow anyone else to help because they won't do it right." 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 attend support group meetings when I am able to go."

The parent states, "I cannot allow anyone else to help because they won't do it right." The parent's statement of not allowing anyone to help because "they won't do it right" supports 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.

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

To describe a functional health problem Establishment of a nursing diagnosis reflects the synthesis of data gathered during a nursing assessment. Gordon suggested a framework for organizing nursing diagnoses based on functional health, thus offering a convenient way to cluster similar diagnoses. The purpose of establishing a nursing diagnosis is not to collaborate with the health care provider, identify medical problems, or to meet accreditation criteria. -Nursing diagnoses relate to problems that the nurse can address independently using nursing interventions, so collaboration with the health care provider is not needed when developing them. -Medical diagnoses, not nursing diagnoses, identify medical problems. -Accreditation does not depend on establishing nursing diagnoses.

What is the purpose of a problem statement?

To describe the health state or health problem of the patient as clearly and concisely as possible

The nurse caring for a morbidly obese client formulates the possible nursing diagnosis, "Imbalanced Nutrition: More than Body Requirements related to excessive food intake as evidenced by morbid obesity." In order to assure the accuracy of the diagnosis, which further step must the nurse take? Interview the client to assess the client's motivation to lose weight. Determine what weight loss programs the client has utilized in the past. Validate with the client that excessive food intake is the cause of the client's obesity. Research the client's medical history to determine the client's usual weight.

Validate with the client that excessive food intake is the cause of the client's obesity. The nurse must discuss the diagnosis with the client to ascertain whether or not the diagnosis is correct. There are other causes of obesity, such as a decrease in activity secondary to surgery. In order to plan effective interventions, it is important to determine the correct etiology. Determining the weight loss programs used by the client and the client's motivation to lose weight are important in planning interventions once the cause is determined. The client's usual weight is not relevant; the obesity may be longstanding.

When used in a nursing diagnosis, the descriptor "impaired" has which meaning? Lack of proportion or relation between corresponding things Weakened or damaged Late, slow, or postponed Consisting of many interconnecting parts or elements

Weakened or damaged The descriptor "impaired" means weakened or damaged, such as in reference to a faculty or function. The descriptor "complicated" means consisting of many interconnecting parts or elements. The descriptor "delayed" means late, slow, or postponed. The descriptor "imbalanced" means lack of proportion or relation between corresponding things.

What is a health promotion nursing diagnosis?

a clinical judgement concerning a patient's motivation and desire to increase well-being and actualize human health potential

What is a problem-focused nursing diagnosis?

a clinical judgment concerning an undesirable human response to a health condition and/or life process that exists in an individual, family, group, or community Examples: fatigue or death anxiety

What is a risk nursing diagnosis?

a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes

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: an impaired cluster interpretation. an ineffective database. a lack of cues, or premature closure. an inaccurate evaluation.

a lack of cues, or premature closure. The lack of adequate cues is called premature closure, which is the case in this situation, as the nurse only has one cue. There is no "cluster" of cues to interpret, so impaired cluster interpretation would not be accurate. It is not so much that the nurse's database is ineffective as it is that the database lacks sufficient data. Evaluation is a separate phase in the nursing process and does not pertain to diagnosis.

A nurse is interviewing an asthmatic client who has a high respiratory rate and at times has difficulty breathing. The client is restless and at current can only speak a few words before pausing to catch a breath. What appropriate nursing diagnosis should the nurse document? altered gas exchange related to the disease condition unable to speak due to ineffective airway clearance altered physical mobility related to tachypnea altered verbal communication related to the breathing problem

altered verbal communication related to the breathing problem The client has a high respiratory rate and difficulty breathing; the client therefore has trouble communicating. Altered verbal communication related to the breathing problem is the appropriate diagnosis. Although altered gas exchange may occur in an asthma attack, it does not relate to the current concern regarding the client's ability to communicate thus it is not the primary concern at this time. There is no evidence that the client is experiencing altered physical mobility due to the condition. Unable to speak due to ineffective airway clearance is not accurate, because the client is able to speak, although the speech is impaired.

What is a health problem?

any condition that requires intervention to promote wellness or to prevent or treat disease or illness

In diagnosing, the registered nurse analyzes _____________________ data to determine actual or potential diagnosis, problems, or issues

assessment

What is a diagnostic error?

failure to detect an actual unhealthy behavior or condition

Medical diagnoses identify __________, whereas nursing diagnoses focus on unhealthy responses to health & __________

diseases; illness

What are the three components of a NANDA nursing diagnosis?

problem, etiology, and defining characteristics

NANDA recommends the use of _______________ or _________________ to limit or specify the meaning of a problem statement

quantifiers or descriptors

When writing an actual nursing diagnosis, the nurse includes the etiology that contributes to the current situation. This would be identified as: defining characteristics. related factors. diagnostic label. problem statement.

related factors. Related factors describe the conditions, circumstances, or etiologies that contribute to the problem. Defining characteristics are the observable "cues" or inferences that cluster as manifestations of an actual illness or wellness health state. The diagnostic label accurately reflects the specific client problem.

What is etiology?

study of the cause of disease

When developing an appropriate nursing diagnosis, the nurse needs to keep in mind that: the signs and symptoms of the disease are part of the information conveyed. the problem's existence requires validation by the health care provider. the interventions planned must be within the nurse's scope of practice. the main focus is on monitoring the body's pathophysiologic response.

the interventions planned must be within the nurse's scope of practice. A nursing diagnosis describes an actual, risk, or health promotion response to a health problem that nurses are responsible for treating independently. Nursing diagnoses describe the client's response to the disease process, developmental stage, or life process and provide a convenient way to communicate nursing therapies or interventions. Nursing diagnoses carry legal ramifications. Only health care problems within the scope of nursing practice may be identified as nursing diagnoses. A nurse may not diagnose a medical disease and is not licensed to independently treat such a problem. Medical diagnoses, not nursing diagnoses, require validation by the health care provider that the problem exists, are focused on pathophysiologic responses of body organs and systems, and convey information about signs and symptoms of disease.

The nurse is aware that nursing diagnoses are:

within the nursing scope of practice to develop and client-focused.