Ch 15 Diagnosing
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 Possible Risk Health promotion
Actual "Ineffective Airway Clearance related to thick tracheobronchial secretions" is an actual nursing diagnosis, because it describes a human response to a health problem that is being manifested. A health promotion nursing diagnosis is a diagnostic statement that describes the human response to levels of wellness in an individual, family, or community that has a potential for enhancement to a higher state. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. A possible nursing diagnosis is made when not enough evidence supports the presence of the problem, but the nurse concludes that it is highly probable and wants to collect more information.
Which type of health problem requires both physician- and nurse-prescribed actions to address? Collaborative health problem Independent health problem Interdisciplinary health problem Physician-developed problem
Collaborative health problem If a problem requires both physician- and nurse-prescribed actions to address, it is by definition a collaborative health problem. The other answers listed are not standard types of health problems.
A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination? Small Bowel Obstruction Bowel Incontinence Ulcerative Colitis Irritable Bowel Syndrome
Bowel Incontinence Bowel incontinence is a NANDA-I-approved nursing diagnosis under the domain of Elimination. Ulcerative colitis, irritable bowel syndrome, and small bowel obstruction are medical diagnoses.
A nurse has selected a nursing diagnosis and is preparing to validate it. With whom would the nurse do this? The unit's nurse manager Client Client's health care provider Another staff nurse
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.
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? "My mother-in-law makes dinner on Tuesdays, and I cannot stand her cooking." "My mother-in-law and I go for a walk daily." "I feel great but wish that I could get more sleep." "I just don't have time to take a shower."
"I just don't have time to take a shower." Any of these statements could be a clue to caregiver role strain when clustered with other evidence. However, the inability to care for oneself, such as not taking time for a shower, strongly indicates that this client is not coping well.
A pregnant client asks the nurse for information on breastfeeding. What type of nursing diagnosis should the nurse formulate? A possible nursing diagnosis A risk nursing diagnosis A health promotion nursing diagnosis An problem-focused nursing diagnosis
A health promotion nursing diagnosis The client is seeking information related to healthy practices. Health promotion nursing diagnoses are formulated to assist the client to meet that need. The client has no health problem, risk of a health problem, or possible problem, so a problem-focused, risk, or possible nursing diagnosis would be inappropriate.
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 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 Homelessness Syndrome related to lack of housing 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.
While developing a plan of care for a client, what should the nurse do before selecting a nursing diagnosis? Verify the primary care provider's written orders. Establish short- and long-term client goals. Collect client subjective and objective data. Perform a focused assessment related to the reason for admission.
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? Promoting safety and preventing harm; detecting and controlling risks Tailoring treatment and medication regimens for each individual Confirming a medical diagnosis Monitoring for changes in health status
Confirming a medical diagnosis The nursing scope of practice dictates what is allowed and not allowed when providing nursing care. Confirming a medical diagnosis is not in the scope of nursing practice. Monitoring for changes in a client's health status, promoting safety and preventing harm, and tailoring treatment and medication regimens to the client's schedule of activities are all nursing care responsibilities.
A 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? Readiness for Enhanced Nutrition related to constipation Diarrhea related to client report of small, loose stools Constipation related to irregular evacuation patterns Bowel incontinence related to depressive state
Constipation related to irregular evacuation patterns This client is experiencing constipation, which is having infrequent or difficult bowel movements, which the nurse believes to be caused by an irregular evacuation pattern--not having a bowel movement for 7 days. There is no evidence that the client needs, much less is ready for, enhanced nutrition related to constipation or that, by implication, that the client's constipation is caused by poor nutrition. There is no evidence that the client is experiencing bowel incontinence, depression, or diarrhea.
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? Contact the client's health care provider. Continue to collect assessment data. Document the data for future reference. Consult with a more experienced nurse.
Consult with a more experienced nurse. A newly graduated nurse does not have the experience to interpret all data. The nurse must recognize when a consult with a more experienced nurse is needed. There is no evidence that the nurse needs to collect more data. The nurse must document the data, but if the data are significant and the nurse does not recognize this and takes no action, it could harm the client. There is no need to contact the health care provider at this time.
A nurse is providing care to several clients who have undergone surgery. When reviewing their electronic health records, which information would the nurse identify as reflecting a nursing diagnosis? Select all that apply. Pain Wound Infection Impaired Skin Integrity Disturbed Body Image Paralytic Ileus
Disturbed Body Image Pain Impaired Skin Integrity Disturbed Body Image, Pain, and Impaired Skin Integrity reflect nursing diagnoses, which are written to describe client problems or issues that nurses can treat independently. Wound Infection and Paralytic Ileus are medical diagnoses or collaborative problems involving potential complications.
The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this baby, but I have always believed that abortion is a sin. I don't know what to do." What nursing diagnosis would be most appropriate for the nurse to formulate? Hopelessness related to inability to decide a course of action as evidenced by the client's statement Ineffective Coping related to rape trauma syndrome as evidenced by client's inability to make a decision Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement Complicated Grieving related to mental trauma as evidenced by the client's inability to make a decision
Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement The client's statement indicates that it is difficult for the client to reach a decision because of the client's moral beliefs. The client is not expressing hopelessness or demonstrating ineffective coping or complicated grieving. The client may be suffering from rape trauma syndrome, but the assessment data do not lead to that diagnosis.
Which component of a nursing diagnosis gives additional meaning to the nursing diagnosis? Descriptors Composition Qualifications Dysfunction
Descriptors Descriptors are words used to give additional meaning to a nursing diagnosis through adding conditions and showing relationships between events. The other answers listed are not components of a nursing diagnosis.
Which describes the best approach for the development of nursing diagnoses? Collaborate with the multidisciplinary team in the formation of nursing diagnoses. Collaborate with the physician in the formation of nursing diagnoses. Develop nursing diagnoses from clusters of significant data. Develop each nursing diagnosis based on a single cue.
Develop nursing diagnoses from clusters of significant data. Nursing diagnoses should always be derived from clusters of significant data, rather than from a single cue. Nursing diagnoses describe client problems that nurses can treat independently and do not require collaboration with other members of the health care team. Therefore, nurses can develop nursing diagnoses without collaborating with physicians or other health care team members.
A nurse documents the following nursing diagnosis on a client's plan of care: "Fluid Volume Deficit related to gastrointestinal upset from food poisoning as evidenced by vomiting and diarrhea for the past three days, slow skin turgor, and weight loss." The nurse identifies which part of the statement as the etiology? Slow skin turgor Fluid volume deficit Gastrointestinal upset from food poisoning Vomiting
Gastrointestinal upset from food poisoning The etiology identifies the physiological, psychological, sociological, spiritual, and environmental factors believed to be related to the problem as either a cause or a contributing factor. The problem is fluid volume deficit. Vomiting and poor skin turgor are defining characteristics.
A nurse documents the following nursing diagnosis on a client's plan of care: "Readiness for Enhanced Breast-Feeding." The nurse has identified which type of nursing diagnosis? Health promotion Risk Problem-focused Syndrome
Health promotion A health promotion nursing diagnosis is a clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential. These responses are expressed by a readiness to enhance specific health behaviors and can be used in any health state. A problem-focused nursing diagnosis is a clinical judgment concerning an undesirable human response to a health condition or life process that exists in an individual, family, group, or community. A risk nursing diagnosis is a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions or life processes. A syndrome nursing diagnosis is a clinical judgment concerning a specific cluster of nursing diagnoses that occur together and are best addressed together and through similar interventions.
The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping? Risk nursing diagnosis Health promotion nursing diagnosis Syndrome nursing diagnosis Actual nursing diagnosis
Health promotion nursing diagnosis Readiness for Enhanced Coping is an example of a health promotion nursing diagnosis. Two cues must be present for a valid health promotion nursing diagnosis: a desire for a higher level of wellness and an effective present status or function. An actual nursing diagnosis represents a problem that has been validated by the presence of major defining characteristics. A risk nursing diagnosis is a clinical judgment that concludes that an individual, family, or community is more vulnerable to develop the problem than are others in the same or a similar situation. A syndrome nursing diagnosis comprises a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation.
Which would be an appropriate nursing diagnosis for a client with cachexia and decreased weight? Lack of Adequate Nutrition Anorexia Nervosa Imbalanced Nutrition: Less than Body Requirements Weight Loss
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 interviewing an older adult client who has experienced a drastic weight loss following a cerebrovascular accident (CVA). The client states, "I have trouble getting groceries because 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 CVA Imbalanced Nutrition: Less than Body Requirements related to drastic weight loss Imbalanced Nutrition: Less than Body Requirements related to difficulty in procuring food Imbalanced Nutrition: Less than Body Requirements related to decreased appetite
Imbalanced Nutrition: Less than Body Requirements related to difficulty in procuring food The client relates the drastic weight loss to the inability to bring food into the house. The client's statement is the most appropriate etiology for the nursing diagnosis. Drastic weight loss is the evidence of imbalanced nutrition. CVA is the medical diagnosis. The client could have had a CVA and still have the ability to grocery shop. There is no evidence that the client has lost appetite.
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 Activity Intolerance Disturbed Sleep Pattern
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 nurse is caring for a client who underwent abdominal surgery today. Which nursing diagnoses would be appropriate for the nurse to identify for this client? Select all that apply. Impaired Mobility related to fear of pain Risk for Infection related to altered tissue integrity Risk for Constipation related to immobility Acute Pain related to disruption of skin tissues secondary to abdominal surgery Potential for Atelectasis related to decreased respirations
Impaired Mobility related to fear of pain Risk for Infection related to altered tissue integrity Risk for Constipation related to immobility Acute Pain related to disruption of skin tissues secondary to abdominal surgery All answers are appropriate, except for the potential for atelectasis. Because this is a potential complication of surgery, it requires a collaborative approach. The other diagnoses are within the scope of practice of nursing.
The nurse is caring for a client who is postoperative day 2 after a total knee replacement. The client refuses to ambulate when the physiotherapist arrives to the unit. The client states, "It is too soon to get up and walk. I am worried my incision will tear open." The nurse correctly documents the problem-focused nursing diagnosis using which statement? Risk for postoperative complications due to disturbed body image. Impaired physical mobility related to anxiety as evidenced by expressed fear of postoperative complications. Risk for anxiety related to fear of ambulating postoperatively. Anxiety related to knowledge deficit regarding normal postoperative activities.
Impaired physical mobility related to anxiety as evidenced by expressed fear of postoperative complications. A problem-focused nursing diagnostic statement contains three parts, sometimes referred to as "PES." P: Name of the health-related issue or problem as identified in the NANDA-I list. E: Etiology (the problem's cause). S: Signs and symptoms, also called defining characteristics. The name of the nursing diagnosis is linked to the etiology with the phrase "related to," and the signs and symptoms are identified with the phrase "as evidenced by." The client's ability to ambulate when expected postoperatively is impaired by anxiety related to fear of postoperative complications. A statement regarding an actual client problem must include what the problem is related to and what evidence the nurse has to indicate that there is a problem. The client is having actually anxiety and is not at risk for it. Beginning the statement with "at risk for" would make the statement inaccurate. The client has not demonstrated a knowledge deficit about normal postoperative activities. The barrier to ambulating is fear and anxiety. There is no evidence to indicate that the client has a disturbed body image. The nurse would have to assess further to confirm this is accurate and include this as evidence in the problem-focused statement.
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 Physical Mobility due to pain Ineffective Movement related to arthritis 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 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? Acute Dyspnea Bronchial Pneumonia Ineffective Airway Clearance Asthma Attack
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.
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 Injury related to client's mismanagement of disease Ineffective Coping related to client's inability to manage the diabetic regimen Ineffective Health Maintenance related to client's denial of illness 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 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.
Which are accurate guidelines when formulating nursing diagnoses? Select all that apply. Write the diagnosis in legally advisable terms. Make sure defining characteristics follow the etiology. Phrase the nursing diagnosis as a client need rather than an alteration. Make sure the client problem precedes the etiology. Include the medical diagnosis in the nursing diagnosis. Be sure the problem statement indicates what is unhealthy about the client.
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 physician or 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.
What association meets every 2 years to further progress in defining, classifying, and describing nursing diagnoses? The Canadian Medical Association (CMA) NANDA-International (NANDA-I) The National League for Nursing (NLN) The Canadian Nurses Association (CNA)
NANDA-International (NANDA-I) NANDA-International (NANDA-I) conferences are held every 2 years, and much progress continues to be made in defining, classifying, and describing nursing diagnoses. The National League for Nursing (NLN) is a national organization for faculty nurses and leaders in nurse education. It offers faculty development, networking opportunities, testing services, nursing research grants, and public policy initiatives to more than 40,000 individual and 1,200 education and associate members. The Canadian Nurses Association is the national professional association representing over 139,000 registered nurses in Canada. The Canadian Medical Association is a national, voluntary association of physicians that advocates on behalf of its members and the public for access to high-quality health care and provides leadership and guidance to physicians.
The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action? Decrease stimulation and allow the client to rest. Notify the physician for additional orders. Consult with another nurse to validate the assessment. Document the client's level of consciousness.
Notify the physician 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 physician. Medication orders are required to treat the electrolyte imbalance. Documenting the level of consciousness is appropriate, but not as the priority action. Another nurse is not necessary to check the nurse's assessment. Decreasing stimulation and allowing the client to rest with no further action may result in harm to the client.
A nurse documents the following in the client chart: Risk for Decreased Cardiac Output related to myocardial ischemia. This is an example of what aspect of client care? 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: Fear related to new diagnosis of myocardial infarction PC: Disturbed Body Image related to decreased activity tolerance PC: Activity Intolerance related to decreased oxygenation capacity PC: Decreased Cardiac Output related to cardiac tissue damage
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 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: inconsistent cues. clustering of cues. premature closure. cluster interpretation.
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.
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? Risk for Infection Transmission related to lack of immunizations Readiness for Enhanced Knowledge: Childhood Immunizations Ineffective Health Maintenance related to lack of knowledge of childhood immunizations Risk for Complications related to childhood illnesses
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.
After completing a client abdominal assessment, the nurse finds diminished bowel sounds. To determine what intervention is needed, which step would the nurse take first? Prepare the client for administration of laxative medication. Provide teaching about prevention of constipation. Review the client's recent food and fluid intake. Encourage the client to drink more fluids and eat more fiber.
Review the client's recent food and fluid intake. The first step in interpreting and analyzing the data involves identifying cues or significant data that raise a red flag. From there, the nurse would look for patterns or clusters of data that signify an actual or possible nursing problem. Preparing the client for laxative administration indicates the nurse has skipped some necessary steps in the nursing process. The nurse must first engage in a process of analysis and interpretation of data prior to formulating a hypothesis about a potential or actual problem. Providing teaching about constipation and encouraging the client to change food and fluid intake assumes the nurse has proceeded logically through each step of the nursing process to develop the conclusion that diminished bowel sounds are the result of constipation. Further data need to be collected, analyzed and interpreted before the nurse can plan and carry out this intervention.
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." To ensure the safety of the client, which nursing diagnosis should the nurse assign to this client and address in the care plan? Knowledge Deficit related to surgical procedure Risk for Injury related to latex allergy Anxiety related to surgical procedure Risk for Allergy Response related to latex allergy
Risk for Allergy Response related to latex allergy To ensure the safety of the client, the nurse should address the risk for an allergic response due to the client's latex allergy. Anxiety refers to a vague feeling of dread; however, the client is responding with fear to a very real threat. There is no evidence that the client does not understand the surgical procedure. Risk for Injury is not an appropriate diagnosis, because it does not adequately address the specific health problem.
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? Deficient Community Health related to chemical plant Risk for Infection related to community contamination Knowledge Deficit related to effects of chemical plant pollution Risk for Community Contamination related to possible environmental pollution
Risk for Community Contamination related to possible environmental pollution The nurse has identified a risk diagnosis because of the unknown health effects of the chemical plant on the community. Risk for Community Contamination would address the broad concerns of the nurse. Knowledge Deficit is not appropriate because it has too narrow a focus. Deficient Community Health is not a NANDA-I diagnosis and the etiology must deal with how the plant may possibly affect the community. Risk for Infection has a very narrow focus. The etiology of community contamination has not been proven.
Which statement appropriately identifies a risk nursing diagnosis for a client who is confined to bed? Risk for Impaired Skin Integrity related to bed rest Immobility related to confinement to bed Ineffective Airway Clearance related to bed rest Potential for Pneumonia related to inactivity
Risk for Impaired Skin Integrity related to bed rest A risk nursing diagnosis, as defined by NANDA-I, "describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community." The client in this scenario is most at risk for skin breakdown related to prolonged confinement to bed; however, proactive and continued nursing interventions can reduce this risk. Ineffective Airway Clearance and Immobility are not risk nursing diagnoses but actually nursing diagnoses, as they describe problems that already exist. Potential for Pneumonia is not a properly worded risk nursing diagnosis; "Risk for" should be included rather than "Potential for."
A nurse is educating a client about care to be taken in nephrotic syndrome. The client expresses that the education is of no use because the disease is not curable. What nursing diagnosis should the nurse formulate with regard to the client's concern? Risk for Powerlessness Disturbed Body Image Impaired Comfort Risk for Suicide
Risk for Powerlessness The most appropriate nursing diagnosis for the client is the Risk for Powerlessness. The client feels that the disease is not under the client's control and any personal efforts will not affect outcome. Disturbed Body Image is not an appropriate answer because the client does not seem to be concerned about the appearance of the body. Impaired Comfort is also not an appropriate nursing diagnosis because the client does not demonstrate any sign of discomfort. There is not enough indication that the client is at risk for suicide.
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 breast cancer Disturbed Body Image as evidenced by client's refusal to look at self Disturbed Body Image related to loss of hair Disturbed Body Image as evidenced by client's negative comments
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.
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 has demonstrated effective coping skills in the past. The client states a belief in a reward in heaven after death. The client states that no one should ever ask for help from others. The client has a long history of health problems. The client has been accompanied by family members to every appointment.
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 "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 requests the minister of the client's church to visit. The client states, "I can't handle all of this." The client reports an inability to get adequate restful sleep. The client asks for information relating to the cancer diagnosis. The client has difficulty concentrating on the details of treatment options.
The client states, "I can't handle all of this." The client reports an inability to get adequate restful sleep. The client has difficulty concentrating on the details of treatment options.
The nurse has identified a nursing diagnosis of "Risk for Impaired Parenting" for a client who has recently learned of being pregnant. What assessment data would be appropriate to lead the nurse to select this diagnosis? The client states, "I do not plan to tell my family about my pregnancy right away." The client states, "I do not know how to take care of a baby." The client states, "I am shocked to find out that I am pregnant." The client states, "I know that I will have to make some changes in my life."
The client states, "I do not know how to take care of a baby." It is not unusual to feel unprepared to care for a baby. However, this warrants the nurse's attention because there is an associated risk of impaired parenting. Being shocked about the pregnancy and being aware of the need to make changes in one's life are normal reactions to finding out about a pregnancy and do not necessarily indicate future problems. The nurse must work with the client about communication with family, but this does not necessarily mean that the client's parenting will be compromised.
Which factor is most likely to contribute to the nurse making a diagnostic error? The client withholds information during the client assessment. The client's subjective and objective data are congruent. The subjective and objective data point to a specific health issue. The client expands on information previously provided.
The client withholds information during the client assessment. Diagnostic errors occur when the database is incomplete. Subjective and objective data that cluster together and point to a specific health problem decrease the likelihood of diagnostic errors. The risk of making a diagnostic error decreases when the client's subjective and objective data are congruent and when the client expands on information previously provided.
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 length of time the client has been in the hospital. The nurse should determine the reason for the client's refusal. The nurse should determine the client's last laboratory results. The nurse should determine what laboratory tests are critical at this time.
The nurse should determine the reason for the client's refusal. Before addressing the issue, the nurse must determine why the client refused the lab draw. It is essential to know the cause before planning how to address the issue. It is immaterial how long the client has been in the hospital, what laboratory tests are critical, or what the client's last results were.
During a home health care visit, the nurse identifies a nursing diagnosis of Caregiver Role Strain for a parent who is caring for a child dependent on a ventilator. What subjective assessment data would support the nurse's diagnosis? The parent states, "I attend support group meetings when I am able to go." The parent states, "A member of my church gives me a break twice a week." The parent states, "I cannot allow anyone else to help because they won't do it right." The parent states, "I make sure that I get regular exercise."
The parent states, "I cannot allow anyone else to help because they won't do it right." The parent'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.
The client is admitted to the surgical unit following an exploratory laparotomy. Which nursing diagnosis is the priority? Fear/anxiety Impaired skin integrity Risk for imbalanced body temperature Deficient knowledge
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 purpose of establishing a nursing diagnosis? To meet accreditation criteria To identify medical problems To describe a functional health problem To collaborate with the physician
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 physician, 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 physician is not needed when developing them. Medical diagnoses, not nursing diagnoses, identify medical problems. Accreditation does not depend on establishing nursing diagnoses.
Assessment of a client with difficulty breathing reveals that the client has thick, tenacious secretions in the trachea and bronchi and excessive sputum with coughing. The respiratory rate is slightly increased. When developing this client's plan of care, which intervention would the nurse include? Tracheobronchial suctioning Assisted ambulation Limit fluids to 1,000 ml per day Mechanical ventilation
Tracheobronchial suctioning Based on the assessment of the client, the nurse should identify specific cues, such as thick secretions, excessive sputum, and coughing, that indicate a problem with the client's ability to maintain a clear airway. Tracheobronchial suctioning would be the appropriate intervention to clear the client's airway. The nurse would increase fluids to thin secretions, not limit fluid intake for this client. As the client is experiencing difficulty breathing, not problems with ambulation, assisted ambulation is not necessary. The client is breathing independently; therefore, mechanical ventilation is not necessary.
When used in a nursing diagnosis, the descriptor "impaired" has which meaning? Lack of proportion or relation between corresponding things Consisting of many interconnecting parts or elements Late, slow, or postponed Weakened or damaged
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.
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. syndrome nursing diagnoses. dependent nursing diagnoses.
actual or potential nursing diagnoses. Nursing diagnoses are established based on actual or potential health problems that are identified by the nurse and can be independently addressed. Collaborative diagnoses are selected when the nurse needs to work with another member of the health care team to assist the client in resolving the health issue. Dependent nursing diagnoses require a specific written order from the primary health care provider for a nurse to address. Syndrome nursing diagnoses address a cluster of actual or risk diagnoses that are predicted to be present as a result of a certain event or situation.
The nurse recognizes that health problems that the nurse can address by independent nursing interventions are called: dependent nursing diagnoses. actual or potential nursing diagnoses. collaborative nursing diagnoses. syndrome nursing diagnoses.
actual or potential nursing diagnoses. Nursing diagnoses are established based on actual or potential health problems that are identified by the nurse and can be independently addressed. Collaborative diagnoses are selected when the nurse needs to work with another member of the health care team to assist the client in resolving the health issue. Dependent nursing diagnoses require a specific written order from the primary health care provider for a nurse to address. Syndrome nursing diagnoses address a cluster of actual or risk diagnoses that are predicted to be present as a result of a certain event or situation.
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 altered physical mobility related to tachypnea altered verbal communication related to the breathing problem unable to speak due to ineffective airway clearance
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.
