Diagnosing

The nurse is formulating nursing diagnoses pertaining to a client with pancreatic cancer. Which of the following factors would the nurse identify as strengths of the client? (Select all that apply.)

• The client has been accompanied by family members to every appointment. • The client has demonstrated effective coping skills in the past. • The client states a belief in a reward in heaven after death.

Actual

problem is present.

Potential problem

may occur; defining characteristics are present as risk factors.

Which of the following reflect the diagnosis stage? Select all that apply.

"Based on what you have told me, it seems that urinary incontinence is a problem for you. What do you think?" • The nurse identifies that the client has effectively coped with health stressors in the past. • The nurse identifies that the client who is on strict bed rest is at risk for impaired skin integrity. Explanation: Diagnosing would include identifying the client's strengths (past effective coping) and potential health problems (risk for impaired skin integrity) and validating the nursing diagnosis with the client (urinary incontinence). Assisting the client with ambulation would occur in the implementation stage. Determining that the client needs to be less active would occur in the evaluation stage. (less)

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

A set of clinical cues Explanation: Each piece of client information is considered a clinical cue; a set of clinical cues forms a cluster that is present if the diagnosis is accurate.

A client with congestive heart failure has dyspnea while ambulating to the bathroom. The nurse selects the nursing diagnosis of "Activity intolerance" to address this health problem. Which of the following would be appropriate to select as the etiology of this nursing diagnosis?

Compromised oxygen transport Explanation: The pathophysiology of congestive heart failure decreases the body's ability to transport oxygen through the body. There is no evidence of client's unwillingness to ambulate. Cardiac disease is a medical diagnosis. Shortness of breath is the evidence that leads to the diagnosis of "Activity intolerance."

The formulation of nursing diagnoses is unique to the nursing profession. Which statement accurately represents a characteristic of diagnosing?

Nurses write nursing diagnoses to describe patient problems that nurses can treat.

What is the purpose of establishing a nursing diagnosis?

To describe a functional health problem.

A male client age 67 years has right lower quadrant pain that has been diagnosed as appendicitis and subsequently treated by open appendectomy. How should the nurse document a potential complication related to this patient's diagnosis and treatment?

To write a diagnostic statement for a collaborative problem, focus on the potential complications of the problem. Use "PC" (for potential complication), followed by a colon, and list the complications that might occur. For clarity, link the potential complications and the collaborative problem by using "related to."

he nurse caring for a morbidly obese client formulates the possible nursing diagnosis, "Imbalanced nutrition: More than body requirements related to excessive food intake as evidenced by morbid obesity." In order to assure the accuracy of the diagnosis, what further step must the nurse take?

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

When the initial nursing assessment revealed that a patient had not had a bowel movement for 2 days, the student nurse wrote the diagnostic label "constipation." Which of the following comments is the nurse most likely to hear from the instructor? a. "Hold on a minute . . . Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue." b. "Job well done . . . you've identified this problem early and we can manage it before it becomes more acute." c. "Is this an actual or a possible diagnosis?" d. "This is a medical, not a nursing problem."

a. A data cluster is a grouping of patient data or cues that points to the existence of a patient health problem. Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue. There may be a reason for the lack of a bowel movement for 2 days, or it might be this individual's normal pattern.

To determine the significance of a blood pressure reading of 148/100, it is first necessary for the nurse to: a. Compare this reading to standards. b. Check the taxonomy of nursing diagnoses for a pertinent label. c. Check a medical text for the signs and symptoms of high blood pressure. d. Consult with colleagues.

a. A standard, or a norm, is a generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category. For example, when determining the significance of a patient's blood pressure reading, appropriate standards include normative values for the patient's age group, race, and illness category. Deviation from an appropriate norm may be the basis for writing a diagnosis.

Which of the following nursing diagnoses are written correctly? (Select all that apply.) a. Deficient Fluid Volume related to abnormal fluid loss b. Risk for Impaired Skin Integrity c. Grieving related to Body Image Disturbance d. Possible Chronic Low Self-Esteem e. Nutrition Deficit related to inability to eat a balanced diet f. Knowledge Deficit related to noncompliance with physical therapy routine

a. Deficient Fluid Volume related to abnormal fluid loss b. Risk for Impaired Skin Integrity d. Possible Chronic Low Self-Esteem

Which of the following is an actual or potential health problem that can be prevented or resolved by an independent nursing intervention? a. Nursing diagnoses b. Nursing assessments c. Medical diagnoses d. Collaborative problems

a. Nursing diagnoses

Which of the following are parts of a nursing diagnosis? (Select all that apply.) a. Problem b. Etiology c. Patient needs d. Defining characteristics e. Medical diagnosis f. Legal parameters for nursing actions

a. Problem b. Etiology d. Defining characteristics

nursing diagnoses:

actual or potential health problem that an independent nursing intervention can prevent or resolve. Actual problem is present. Possible problem may be present, but more data are needed to confirm or disconfirm the problem. Potential problem may occur; defining characteristics are present as risk factors.

A nurse is caring for an older adult patient who presents with labored respirations, productive cough, and fever. What would be appropriate nursing diagnoses for this patient? Select all that apply. a. Bronchial pneumonia b. Impaired gas exchange c. Ineffective airway clearance d. Potential complication: sepsis e. Infection related to pneumonia f. Risk for septic shock

b, c, f. Nursing diagnoses are actual or potential health problems that can be prevented or resolved by independent nursing interventions, such as impaired gas exchange, ineffective airway clearance, or risk for septic shock. Bronchial pneumonia and infection are medical diagnoses, and "potential complication: sepsis" is a collaborative problem.

A registered nurse is writing a diagnosis for a 28-year-old male patient who is in traction due to multiple fractures from a motor vehicle accident. Which nursing actions are related to this step in the nursing process? Select all that apply. a. The nurse uses the nursing interview to collect patient data. b. The nurse analyzes data collected in the nursing assessment. c. The nurse develops a care plan for the patient. d. The nurse points out the patient's strengths. e. The nurse assesses the patient's mental status. f. The nurse identifies community resources to help his family cope.

b, d, f. The purposes of diagnosing are to identify how an individual, group, or community responds to actual or potential health and life processes; identify factors that contribute to or cause health problems (etiologies); and identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems. In the diagnosing step of the nursing process, the nurse interprets and analyzes data gathered from the nursing assessment, identifies patient strengths, and identifies resources the patient can use to resolve problems. The nurse assesses and collects patient data in the assessment step and develops a care plan in the planning step of the nursing process.

A nurse writes nursing diagnoses for patients and their families visiting a community health clinic. Which nursing diagnoses are correctly written as three-part nursing diagnoses? (1) Disabled Family Coping related to lack of knowledge about home care of child on ventilator (2) Imbalanced Nutrition: Less Than Body Requirements related to inadequate caloric intake while striving to excel in gymnastics as evidenced by 20-pound weight loss since beginning the gymnastic program, and greatly less than ideal body weight when compared to standard height weight charts (3) Need to learn how to care for child on ventilator at home related to unexpected discharge of daughter after 3-month hospital stay as evidenced by repeated comments "I cannot do this," "I know I'll harm her because I'm not a nurse," and "I can't do medical things" (4) Spiritual Distress related to inability to accept diagnosis of terminal illness as evidenced by multiple comments such as "How could God do this to me?," "I don't deserve this," "I don't understand. I've tried to live my life well," and "How could God make me suffer this way?" (5) Caregiver Role Strain related to failure of home health aides to appropriately diagnose needs of family caregivers and initiate a plan to facilitate coping as evidenced by caregiver's loss of weight and clinical depression a. (1) and (3) b. (2) and (4) c. (1), (2), and (3) d. All of the above

b. (1) is a two-part diagnosis, (3) is written in terms of needs and not an unhealthy response, and (5) is a legally inadvisable statement.

A nurse makes a clinical judgment that an African American male patient in a stressful job is more vulnerable to developing hypertension than White male patients in the same or similar situation. The nurse has formulated what type of nursing diagnosis? a. Actual b. Risk c. Possible d. Wellness

b. A clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation is a Risk nursing diagnosis.

Which of the following statements describe the purpose of diagnosing? (Select all that apply.) a. To identify a disease in an individual, group, or community b. To identify how an individual, group, or community responds to actual or potential health and life processes c. To identify factors that contribute to, or cause, health problems (etiologies) d. To provide a legal record for actions performed by the nursing staff e. To identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems f. To serve as a basis for the selection of nursing interventions to achieve outcomes for which the nurse is accountable

b. To identify how an individual, group, or community responds to actual or potential health and life processes c. To identify factors that contribute to, or cause, health problems (etiologies) e. To identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems f. To serve as a basis for the selection of nursing interventions to achieve outcomes for which the nurse is accountable

After assessing a patient who is recovering from a stroke in a rehabilitation facility, a nurse interprets and analyzes the patient data. Which of the four basic conclusions has the nurse reached when identifying the need to collect more data to confirm a diagnosis of situational low self-esteem? a. No problem b. Possible problem c. Actual nursing diagnosis d. Clinical problem other than nursing diagnosis

b. When a possible problem exists, such as situational low self-esteem related to effects of stroke, the nurse must collect more data to confirm or disprove the suspected problem. The conclusion "no problem" means no nursing response is indicated. When an actual problem exists, the nurse begins planning, implementing, and evaluating care to prevent, reduce, or resolve the problem. A clinical problem other than nursing diagnosis requires that the nurse consult with the appropriate health care professional to work collaboratively on the problem.

Possible problem

may be present, but more data are needed to confirm or disconfirm the problem.

A nurse assesses a patient and formulates the following nursing diagnosis: Risk for Impaired Skin Integrity related to prescribed bedrest as evidenced by reddened areas of skin on the heels and back. Which phrase represents the etiology of this diagnostic statement? a. Risk for Impaired Skin Integrity b. Related to prescribed bedrest c. As evidenced by d. As evidenced by reddened areas of skin on the heels and back

b."Related to prescribed bedrest" is the etiology of the statement. The etiology identifies the contributing or causative factors of the problem. "Risk for Impaired Skin Integrity" is the problem, and "as evidenced by reddened areas of skin on the heels and back" are the defining characteristics of the problem.

Which of the following statements accurately describe a type of NANDA nursing diagnosis? (Select all that apply.) a. A wellness diagnosis has four components: label, definition, defining characteristics, and related factor. b. A possible diagnosis is a clinical judgment about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness. c. A risk nursing diagnosis is a clinical judgment that an individual, family, or community is more likely to develop the problem than others in the same or similar situation. d. An actual diagnosis represents a problem that has been validated by the presence of major defining characteristics. e. A potential nursing diagnosis is a statement describing a suspected problem for which additional data are needed. f. A syndrome nursing diagnosis comprises a cluster of actual or risk nursing diagnoses that are predicted to be present because of certain events or situations.

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

Which of the following are accurate guidelines for writing nursing diagnoses? (Select all that apply.) a. Phrase the nursing diagnosis as a patient need rather than a patient problem. b. Check to make sure that the patient problem follows the etiology. c. Make sure the patient problem and etiology are linked by the phrase "related to." d. Make sure defining characteristics follow the etiology and are linked by the phrase "as manifested by" or "as evidenced by." e. Write nursing diagnoses in legally advisable terms. f. Use defining characteristics and medical diagnoses in the problem statement.

c. Make sure the patient problem and etiology are linked by the phrase "related to." d. Make sure defining characteristics follow the etiology and are linked by the phrase "as manifested by" or "as evidenced by." e. Write nursing diagnoses in legally advisable terms.

Which of the following statements regarding nursing diagnoses is accurate? a. Nursing diagnoses remain the same for as long as the disease is present. b. Nursing diagnoses are written to identify diseases. c. Nursing diagnoses are written to describe patient problems that nurses can treat. d. Nursing diagnoses focus on identifying healthy responses to health and illness.

c. Nursing diagnoses are written to describe patient problems that nurses can treat.

Which of the following nursing diagnoses would be written when the nurse suspects that a health problem exists but needs to gather more data to confirm the diagnosis? a. Actual b. Potential c. Possible d. Apparent

c. Possible

Which of the following nursing concerns is clearly the responsibility of the nurse? a. Monitoring for changes in health status b. Promoting safety and preventing harm; detecting and controlling risks c. Tailoring treatment and medication regimens for each individual d. All of the above

d. All of the above

A nurse is writing nursing diagnoses for patients in a psychiatrist's office. Which nursing diagnoses are correctly written as two-part nursing diagnoses? (1) Ineffective Coping related to inability to maintain marriage (2) Defensive Coping related to loss of job and economic security (3) Altered Thought Processes related to panic state (4) Decisional Conflict related to placement of parent in a long-term care facility a. (1) and (2) b. (3) and (4) c. (1), (2), and (3) d. All of the above

d. Each of the four diagnoses is a correctly written two-part diagnostic statement that includes the problem or diagnostic label and the etiology or cause.

Which of the following would be an appropriate nursing diagnosis 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? a. High Risk for Injury related to abusive parents b. High Risk for Injury related to impaired home management c. Child Abuse related to unsafe home environment d. High Risk for Injury related to unsafe home environment

d. High Risk for Injury related to unsafe home environment

A nurse is counseling a 60-year-old female patient who refuses to look at or care for a new colostomy. She tells the nurse, "I don't care what I look like anymore, I don't even feel like washing my hair, let alone changing this bag." The nurse diagnoses Altered Health Maintenance. This is an example of what type of problem? a. Collaborative problem b. Interdisciplinary problem c. Medical problem d. Nursing problem

d. Nursing Problem, because it describes a problem that can be treated by nurses within the scope of independent nursing practice. Collaborative and interdisciplinary problems require a teamwork approach with other health care professionals to resolve the problem. A medical problem is a traumatic or disease condition validated by medical diagnostic studies.