Chapter 15:Diagnosing

The nurse has been assigned to a group of clients. Which client should be the nurse's priority?

A 32-year-old client with a urinary tract infection who is receiving an intravenous antibiotic and reporting swelling in the tongue. The client receiving the intravenous antibiotic may be experiencing a possible airway obstruction secondary to an allergic reaction and should be the nurses first priority. Caring for a postoperative client reporting pain is important, but the client is not at risk of further deterioration if not cared for immediately. A client with an oxygen saturation of 91% is within normal limits and not the nurse's priority. A client with a low hemoglobin and symptoms of anemia is not in eminent danger and not the nurse's first priority.

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 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 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. 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 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 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.

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 difficulty in procuring food Explanation: 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 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.

Which is the best example of a nursing diagnosis?

Ineffective Breastfeeding related to latching as evidenced by nonsustained suckling at the breast. Explanation: 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 teenager 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?

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 teenager 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 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?

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.

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

Reporting signs and symptoms related to the client's kidney failure In producing a nursing diagnosis, a nurse creates accountability for detecting and reporting the signs and symptoms of a medical diagnosis. The nurse is not legally responsible for independently managing or coordinating the client's treatment. Choosing and performing interventions to resolve the condition is primarily within the purview of the physician.

A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern?

Risk for Community Contamination related to possible environmental pollution 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 would be an appropriate nursing diagnosis for a client with cachexia and decreased weight?

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.

When reviewing the client's history, the nurse notes that the client's last documented bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "Constipation," what assessment must the nurse make?

The nurse should determine the client's normal bowel elimination pattern. Explanation: To validate the diagnosis, the nurse must determine what is normal for the client. Dietary habits may contribute to constipation, but the nurse must first confirm that the client is actually constipated. Likewise, bowel sounds might help explain the cause of constipation, but the nurse should first confirm that the client is constipated. There is no standard elimination pattern; it is highly individualized.

A client with diabetes mellitus has been admitted to the hospital in diabetic ketoacidosis. During the admission assessment of the client, the nurse learns that the client is not following the prescribed therapeutic regimen. The client states, "I don't really have diabetes. My doctor overreacts." What is the most appropriate diagnosis for this client's health problem?

ineffective Health Maintenance related to client's denial of illness The 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 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. 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.