Chapter 16: Diagnosis/Problem Identification
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." "I feel great but wish that I could get more sleep." "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 just don't have time to take a shower." Explanation: 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.
The nurse is caring for a client whose health problem requires both health care provider- and nurse-prescribed actions to address. What type of problem is being addressed for this client? Independent health problem Interdisciplinary health problem Health care provider-developed problem Collaborative health problem
Collaborative health problem Explanation: If a problem requires both health care provider- 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.
Which example of client care is not the responsibility of the nurse? Tailoring treatment and medication regimens for each individual Promoting safety and preventing harm; detecting and controlling risks Confirming a medical diagnosis Monitoring for changes in health status
Confirming a medical diagnosis Explanation: 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? Constipation related to irregular evacuation patterns Readiness for Enhanced Nutrition related to constipation Diarrhea related to client report of small, loose stools Bowel incontinence related to depressive state
Constipation related to irregular evacuation patterns Explanation: 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? Consult with a more experienced nurse. Document the data for future reference. Continue to collect assessment data. Contact the client's health care provider.
Consult with a more experienced nurse. Explanation: 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.
The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this infant, 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? 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 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 Explanation: 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.
The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this infant, but I have always believed that abortion is a sin. I don't know what to do." What nursing diagnosis would be most appropriate for the nurse to formulate? Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement Hopelessness related to inability to decide a course of action as evidenced by the client's statement Complicated Grieving related to mental trauma as evidenced by the client's inability to make a decision 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 Explanation: 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.
After meeting with a client and their family, the nurse has identified a nursing diagnosis of Effective Family Coping. In this diagnosis, the term "Effective" constitutes what part of the nursing diagnosis? Qualifier Descriptor Amendment Composition
Descriptor Explanation: Descriptors or modifiers are words used to give additional meaning to a nursing diagnosis through adding conditions and showing relationships between events, such as characterizing the family's coping as being effective.. These components of a nursing diagnosis are not referred to as amendments, qualifiers or compositions.
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? Gastrointestinal upset from food poisoning Slow skin turgor Vomiting Fluid volume deficit
Gastrointestinal upset from food poisoning Explanation: 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.
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 Actual nursing diagnosis Syndrome nursing diagnosis
Health promotion nursing diagnosis Explanation: 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.
A nurse is caring for a toddler who has been treated on two different occasions for lacerations and contusions due to the parents' negligence in providing a safe environment. What is an appropriate nursing diagnosis for this client? High Risk for Injury related to unsafe home environment High Risk for Injury related to impaired home management Child Abuse related to unsafe home environment High Risk for Injury related to abusive parents
High Risk for Injury related to unsafe home environment Explanation: The nursing diagnosis "High Risk for Injury related to unsafe home environment" is appropriate because it contains the NANDA-I nursing diagnosis problem statement and the etiology of the problem. High Risk for Injury related to abusive parents is accusatory and may not be accurate. High Risk for Injury related to impaired home management does not accurately identify the etiology of the problem. Child Abuse is not a NANDA-I approved nursing diagnosis.
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 drastic weight loss Imbalanced Nutrition: Less than Body Requirements related to decreased appetite Imbalanced Nutrition: Less than Body Requirements related to difficulty in procuring food Imbalanced Nutrition: Less than Body Requirements related to CVA
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 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? Impaired Movements due to pain Ineffective Physical Mobility due to pain Ineffective Movement related to arthritis Impaired Physical Mobility related to pain
Impaired Physical Mobility related to pain Explanation: "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.
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 at 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. Risk for anxiety related to fear of ambulating postoperatively. Impaired physical mobility related to anxiety as evidenced by expressed fear of postoperative complications. Anxiety related to knowledge deficit regarding normal postoperative activities.
Impaired physical mobility related to anxiety as evidenced by expressed fear of postoperative complications. Explanation: 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.
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. Gastroesophageal Reflux related to low stomach pH as evidenced by foul breath and burning sensation in throat. Cellulitis related to infection as evidenced by warm, reddened skin.
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 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 Ineffective Airway Clearance related to bronchial constriction Knowledge Deficit: Medications related to new medical diagnosis Noncompliance related to deficient knowledge of a new medical diagnosis
Knowledge Deficit: Medications related to new medical diagnosis Explanation: 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.
The nurse has completed a comprehensive assessment of a client and is considering possible nursing diagnoses. In order to be selected, the nurse must ensure the nursing diagnosis meets what criterion? Legally treatable by a registered nurse LInked to the client's pathophysiology. A consequence of a medical diagnosis Corroborated by the primary care provider.
Legally treatable by a registered nurse Explanation: The scope of practice of registered nurses determines what interventions nurses are permitted to perform. Because nurses are responsible for addressing any problems they identify in their diagnoses, they may only include in their diagnoses problems that they may address using interventions that are within their scope of practice to perform. A nursing diagnosis may not be established by a health care provider or other non-nurse professional. Many nursing diagnoses are not rooted in pathophysiology or medical diagnoses, such as the diagnosis of Effective Family Coping.
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? Medical diagnosis Nursing diagnosis Collaborative problem Nursing assessment
Nursing diagnosis Explanation: 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.
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? Provide teaching about the prevention of constipation. Encourage the client to drink more fluids and eat more fiber. Prepare the client for administration of laxative medication. Review the client's recent food and fluid intake.
Review the client's recent food and fluid intake. Explanation: 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 needs 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 Risk for Allergy Response related to latex allergy Anxiety related to surgical procedure
Risk for Allergy Response related to latex allergy Explanation: 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? Risk for Infection related to community contamination Risk for Community Contamination related to possible environmental pollution Knowledge Deficit related to effects of chemical plant pollution Deficient Community Health related to chemical plant
Risk for Community Contamination related to possible environmental pollution Explanation: 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? Ineffective Airway Clearance related to bed rest Potential for Pneumonia related to inactivity Immobility related to confinement to bed Risk for Skin Breakdown related to bed rest
Risk for Skin Breakdown related to bed rest Explanation: A risk nursing diagnosis,is "a clinical judgment concerning the susceptibility of an individual. 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."
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 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 an infant."
The client states, "I do not know how to take care of an infant." Explanation: It is not unusual to feel unprepared to care for a infant. 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.
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.
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, "I make sure that I get regular exercise." 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 cannot allow anyone else to help because they won't do it right." Explanation: 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 nurse is caring for a client who is experiencing a collaborative problem. The nurse should plan the client's care based on an understanding that this problem is characterized by: a risk or wellness human response to health problems. a result of disease, trauma, treatment, or diagnostic studies. a convenient means for communication among team members. an emergent condition that requires rapid nursing response.
a result of disease, trauma, treatment, or diagnostic studies. Explanation: The collaborative problem results from disease, trauma, treatment, or diagnostic studies. Collaborative problems require health care provider-prescribed and nurse-prescribed actions. The medical diagnosis requires and provides health care provider-prescribed actions for treatment. A nursing diagnosis describes a risk or wellness human response to health problems. Collaborative problems may or may not require immediate action. They do not necessarily provide a convenient means of communication among team members. Reference:
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. clustering of cues. inconsistent cues. cluster interpretation.
premature closure. Explanation: 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.
