FUNDS II Chapter 4. Nursing Process: Diagnosis

Using Maslow's Hierarchy of Needs, rank the following nursing diagnoses in order of importance, beginning with the highest-priority diagnosis. (Enter using the following format: 1, 2, 3, 4) 1) Anxiety 2) Risk for infection 3) Disturbed body image 4) Sleep deprivation

ANS: 4, 2, 1, 3 In Maslow's hierarchy, physiological needs and safety are the highest priority. Sleep is a basic physiological need. Infection can threaten physical health. In this question, infection is not present; therefore, there is only a risk for it. Sleep Deprivation is an immediate problem that affects general physical, mental, and emotional health. Neither Anxiety nor Disturbed Body image is a physiological or safety need. Anxiety is a more immediate need than is Disturbed Body Image; therefore, it probably deserves a higher ranking. Remind students that the ranking would depend on the severity of each problem, which is not known by the labels alone.

What is wrong with the following diagnostic statement? "Impaired Physical Mobility related to laziness and not having appropriate shoes." The statement is: a) Judgmental b) Too complex c) Legally questionable d) Without supportive data

ANS: A "Lazy" implies criticism of the client and therefore is judgmental. There need to be several (certainly more than two) etiological factors for the statement to be complex. There is no blame implied or harm resulting, so the statement is not legally questionable. There is no minimum "amount" of supportive data for a diagnosis and the stated etiology related to the nursing diagnosis. No supportive data are given in the stem of the question, so you could not choose "lack of data" as the best answer because all the options lack data as far as you can tell from the information given in the question. In addition, it is not necessary to include supportive data in the diagnostic statement (although some do prefer to use AMB and include defining characteristics).

Which of the following is an example of a cluster of related cues? a) Complains of nausea and stomach pain after eating b) Has a productive cough and states stools are loose c) Has a daily bowel movement and eats a high-fiber diet d) Respiratory rate 20 breaths/min, heart rate 85 beats/min, blood pressure 136/84 mm Hg

ANS: A A cue is an unhealthy response; a cluster of cues consists of cues related to each other, such as nausea and stomach pain after eating. Productive cough and loose stools are abnormal findings but are not obviously or usually related to each other. Daily bowel movement and high-fiber diet are related but normal responses. The vital signs are also within normal limits.

After identifying problems and etiologies and prior to writing a nursing diagnosis statement, the nurse would: a) Verify the nursing diagnosis with the patient b) Verify information with the primary care provider c) Check the medical diagnosis for consistency in treatments d) Review the data and the diagnosis with another nurse

ANS: A After identifying problems and etiologies, the nurse must verify them with the patient. A diagnostic statement is an interpretation of the data and the patient's interpretation may not be the same as that of the nurse. Verifying information with the primary care provider does not assist the nurse in developing a plan of care based on nursing diagnoses and interventions. Checking the medical diagnosis for consistency in treatments does not assist the nurse in tailoring the nursing diagnosis to individual patient needs, although when planning care, the nurse does need to be certain that nursing interventions do not conflict with medical therapies. Reviewing the data and the diagnosis with another nurse may reaffirm the nurse's conclusions; however, the diagnosis still needs to be verified with the patient.

The diagnostic label, or patient problem, is used primarily to suggest: a) Client goals b) Cue clusters c) Interventions d) Etiology

ANS: A As a general rule, the problem suggests goals for client outcomes. The etiology suggests interventions. Cue clusters support whether the correct nursing diagnosis has been identified.

Which of the following is a criticism of standardized nursing diagnoses developed by NANDA-I? a) There is little research to support nursing diagnosis labels. b) A perfect nursing diagnosis must be written for it to be useful. c) Standardized diagnoses are not included in all states' nurse practice acts. d) Other professions do not recognize nursing diagnoses.

ANS: A Best practice is evidence-based practice; that is, it is developed through sound, scientific research. Research is currently being conducted, but many of the diagnoses are not research based. A perfect nursing diagnosis is impossible to write, so that is not an issue. Having standardized nursing diagnoses recognized in state practice acts or by other professions has nothing to do with the value of the NANDA-I taxonomy. ANS: 4, 2, 1, 3 In Maslow's hierarchy, physiological needs and safety are the highest priority. Sleep is a basic physiological need. Infection can threaten physical health. In this question, infection is not present; therefore, there is only a risk for it. Sleep Deprivation is an immediate problem that affects general physical, mental, and emotional health. Neither Anxiety nor Disturbed Body image is a physiological or safety need. Anxiety is a more immediate need than is Disturbed Body Image; therefore, it probably deserves a higher ranking. Remind students that the ranking would depend on the severity of each problem, which is not known by the labels alone.

Which statement made by the nurse is an example of stereotyping? a) "Be sure to take your shoes off when entering a Japanese family's home." b) "Patients with type 1 diabetes do not make insulin; therefore, they will need to take insulin regularly." c) "The patient in room 3 cries every time she gets out of bed. She needs to understand that getting out of bed is helping her." d) "My 2-year-old child never had a temper tantrum. I don't understand why the 2-year-old child in room 4 is having one."

ANS: A Stereotypes are judgments and expectations about an individual based on the personal beliefs one may have about a specific group. The statement to remove shoes in a Japanese family's home is stereotyping this particular culture. Patients with type 1 diabetes will need insulin therapy, as this is a medical treatment for all patients with diabetes. The comment related to the patient in room 3 needing to get out of bed is judgmental. The example of the 2-year-old demonstrates a bias, as the nurse is reflecting her opinion of this 2-year-old based on her personal opinion.

The patient verbalizes an overwhelming lack of energy. He says, "I still feel exhausted even after I sleep. I feel guilty when I can't keep up with my usual daily activities or sleep during the day. I've been a little depressed lately, too." The patient seems to have difficulty concentrating, but has no apparent physical problems. Which of the following diagnoses best describes his health status? a) Fatigue related to depression b) Fatigue related to difficulty concentrating c) Guilt related to lack of energy d) Chronic confusion related to lack of energy

ANS: A The diagnosis that best describes the overall health status is Fatigue. The only cue that might cause Fatigue is depression. You cannot use depression as the problem because it is a medical diagnosis, and it is not a NANDA-I label. The other cues (difficulty concentrating, lack of energy, and guilt) are symptoms of Fatigue, not etiologies. These diagnoses would lead the nurse to focus on dealing with guilt and confusion, so the source of the Fatigue would not be addressed.

Which of the following regarding nursing diagnosis are accurate? Select all that apply. a) Provide the basis for nursing interventions b) Are validated with patient and family when possible c) Have historically been well substantiated by research d) Are descriptions of pathological disease processes

ANS: A, B Nursing diagnosis is the second step in the Nursing Process. It is the link between the preceding assessment data and all future phases. It further provides the basis for planning client-centered goals and interventions. When possible, the nursing diagnosis as well as all other steps in the Nursing Process should be validated with the patient. The diagnostic statement is written after all data are collected and reflects the nurse's clinical reasoning in establishing the nursing problem. Nursing diagnoses are human responses to health problems, whereas medical diagnoses establish disease processes. Many nursing diagnoses have been verified and established through research; however, this has not been a historical strength of the taxonomy. This continues to be a criticism of nursing diagnosis.

The benefits for nursing practice in using a standardized nursing language include which of the following? Select all that apply. a) Define and communicate nursing knowledge b) Assist the nurse in understanding medical diagnoses c) Facilitate nursing research d) Help nurses provide consistent interventions for all patients

ANS: A, C Standardized nursing languages are a comparatively recent attempt to bring clarity to communication about nursing knowledge and nursing thinking. A standardized language can define, communicate, and expand nursing knowledge, increase visibility and awareness of nursing interventions, facilitate research, and improve patient care by providing better communication among nurse and other healthcare providers. A medical diagnosis describes a disease, illness, or injury. Its purpose is to identify a pathology so that appropriate medical treatment can be given. Nurses deliver nursing care and actions in different ways for different patients. All patients do not have the same needs and problems; therefore, care is planned on an individual basis.

Which of the following is an example of a problem that nurses can treat independently? a) Hemorrhage b) Nausea c) Fracture d) Infection

ANS: B A nursing diagnosis (or nursing problem) is a human response to a disease, injury, or other stressor that nurses can identify, prevent, or treat independently. Nausea is the only problem that meets that criterion; all others are medical or collaborative problems.

How does a risk nursing diagnosis differ from a possible nursing diagnosis? a) A risk diagnosis is based on data about the patient. b) A possible diagnosis is based on partial (or incomplete) data. c) Nurses collect the data to support risk diagnoses. d) A possible diagnosis becomes an actual diagnosis when symptoms develop.

ANS: B A possible nursing diagnosis is based on nursing knowledge, intuition, and experience and does not have enough data to support it; it is based on incomplete data. A risk diagnosis describes a problem that may develop in a vulnerable client if nursing care is not initiated to prevent it; it is made when risk factors are present in the data. Nurses collect data to support both risk and possible diagnoses; therefore, this statement does not differentiate them. A risk diagnosis becomes an actual diagnosis when symptoms develop.

Based only on Maslow's Hierarchy of Needs, which nursing diagnosis should have the highest priority? a) Self-Care Deficit b) Risk for Aspiration c) Impaired Physical Mobility d) Functional Urinary Incontinence

ANS: B Highest priority is given to problems that are life threatening or that could be destructive to the client. Safety is most basic in Maslow's hierarchy. Even though Risk for Aspiration is not an actual problem, it poses the most immediate life-threatening risk to the client; nursing interventions must be performed to prevent it from becoming an actual problem.

Which statement related to prioritizing patient problems is most accurate? a) Nurses must resolve one problem before addressing another problem. b) Nurses prioritize problems in order of urgency. c) Actual problem always take priority over risk problems. d) Nurses give the highest priority to problems that the patient thinks are most important.

ANS: B Patients often have more than one problem, so the nurse must use nursing judgment to decide which to address first and which can wait. Nurses do not need to resolve one problem before attending to another. Actually, in many circumstances nurses may be assessing and intervening for several problems at the same time. Prioritization implies a ranking of urgency to patient problems according to the degree of threat they pose to the patient's life or to the immediacy with which treatment is needed. Highest priority is always given to life-threatening problems; however, not all patient problems are life threatening. Frequently, nurses encounter risk problems that may earn a higher priority ranking than an actual problem. Giving priority to problems tht the patient thinks are most important is important, providing this does not conflict with the basic/survival needs or medical treatments.

Which of the following reflects the most accurate use of an etiology? a) Knowledge deficit related to abdominal ultrasound b) Knowledge deficit related to incorrect use of walker c) Knowledge deficit related to diabetes d) Knowledge deficit related to age

ANS: B Etiologies contain factors that cause, contribute to, or create a risk to the health problem. These contributing factors can be independently acted upon by a nurse. Knowledge deficit (abdominal ultrasound) describes the knowledge problem; lack of prenatal teaching describes the likely reason for the Knowledge deficit and is a factor the nurse can address independently. Knowledge deficit (use of walker) has no etiology. Knowledge deficit (use of walker) r/t muscle weakness is illogical. Muscle weakness may be interfering with the ability to use the walker; however, it is not a factor contributing to the problem of Knowledge deficit. Knowledge deficit related to diabetes is incorrect because diabetes is a medical diagnosis that a nurse cannot act upon without direction or PCP orders. Age is not specified in the example and is demographic data that cannot be altered; this etiology is too vague and general to be useful.

Which of the following nursing diagnosis statements, using the three-part format (PES), are correct? Select all that apply. a) Chronic pain related to osteoarthritis AMB rates pain at 8 on a 0 to 10 pain scale and has difficulty with ambulation. b) Ineffective airway clearance related to excessive mucus AMB cough, shortness of breath, change in respiratory rate and rhythm c) Caregiver role strain related to increasing care needs AMB wife states, "He is just getting too heavy for me to lift" d) Anxiety (moderate) related to cardiac catheterization AMB crying and yelling at family members

ANS: B, C The ineffective airway clearance and caregiver role strain statements contain all components of a correctly written nursing diagnosis statement. The problems are stated in correct NANDA-I format and reflect a patient response to a health problem. The connecting "related to" statements reflect etiologies that cause or contribute to the health problem and can direct nursing interventions. The AMBs reflect signs and symptoms that have validated the patient response to the health problem. The statement beginning with "Chronic pain" contains an etiology that is a medical diagnosis and cannot be used by the nurse to act on independently. The anxiety statement contains an etiology that describes a diagnostic procedure and cannot be independently acted on by a nurse.

The patient shows the necessary defining characteristics, and the nurse has diagnosed Decisional Conflict related to unclear personal values and beliefs. What essential action should the nurse take to help ensure the accuracy of this diagnosis? a) Ask a more experienced nurse to confirm it. b) Request a social worker interview the patient. c) Ask the patient to confirm the diagnosis. d) Read about Decisional Conflict in the NANDA-I handbook.

ANS: C After identifying problems and etiologies (which this nurse has done), the nurse should verify them with the patient to help ensure that her conclusions are accurate. If the patient does not agree that he has Decisional Conflict, the nurse might interview him more in depth to clarify the meaning of the data. Certainly the nurse could ask another nurse's opinion, but that is not essential. It would make no sense to have a social worker interview the patient unless the situation remains unclear even after confirming with the client. If the nurse did have adequate theoretical knowledge of Decisional Conflict for this patient, she should have been informed by reading the NANDA-I handbook before making the diagnosis. If the patient does not confirm the diagnosis, and the nurse concludes the diagnosis is in error, she might then reread the NANDA-I guide.

Which of the following is the best approach to validate a clinical inference? a) Have another nurse evaluate it b) Have the physician evaluate it c) Have sufficient supportive data d) Have the client's family confirm it

ANS: C All clinical inferences should be well supported by data. The more reliable the data are that you gather, the more certain you can be that your inference is accurate. Because inferences are nursing diagnoses, it would be inappropriate to have a physician evaluate them. Although another experienced nurse could evaluate the inference, it still needs to be supported by sound and sufficient data. Even clients can validate clinical inferences in some situations; however, adequate supporting data are still needed. Keep in mind that the client's data might or might not be sufficient to "prove" the inference.

Which of the following most accurately describes nursing diagnoses? A nursing diagnosis: a) Supports the nurse's diagnostic reasoning b) Supports the client's medical diagnosis c) Identifies a client's response to a health problem d) Identifies a client's health problem

ANS: C Nursing diagnoses are statements that nurses use to describe a client's physical, mental, emotional, spiritual, and social response to disease, injury, or other stressor. Diagnostic reasoning is used to identify the appropriate nursing diagnosis; it is not meant to "support" the diagnosis. A health problem is a condition that requires intervention to promote wellness or prevent illness; it is sometimes, but not always, a nursing diagnosis. Nursing diagnoses are not medical diagnose

Which nursing diagnosis is written in the correct format when using the NANDA-I taxonomy? a) Bowel Obstruction related to recent abdominal surgery AMB: nausea, vomiting, and abdominal pain b) Inability to Ingest Food related to imbalanced nutrition: less than body requirements A.M.B. inadequate food intake, weight less than 20% under ideal body weight c) Impaired Skin Integrity related to physical immobility AMB skin tear over sacral area d) Caregiver Role Strain related to alienation from family and friends AMB 24-hour care responsibilities

ANS: C The components of NANDA-I nursing diagnosis might include the following four parts: diagnostic label, defining characteristics, related factors, and risk factors. "Impaired Skin Integrity . . ." has the problem statement, etiology, and symptoms. For "Bowel Obstruction . . ." the problem is a medical diagnosis. The cause-and-effect order of "Inability to Ingest Food . . ." is incorrect; it starts with the etiology. The etiology and symptoms (A.M.B.) of "Caregiver Role Strain . . ." are reversed (alienation from family and friends are the symptoms that support the diagnosis).

Which nursing diagnosis is written in the correct format? a) Imbalanced Nutrition: Less than Body Requirements related to body weight less than 20% under ideal weight b) Ineffective Airway Clearance related to increased respiratory rate and irregular rhythm c) Impaired Swallowing related to absent gag reflex d) Excess Fluid Volume related to 3 lb weight gain in 24 hours

ANS: C The etiology should describe what is causing or contributing to the problem. The etiologies for Ineffective Airway Clearance, Impaired Swallowing, and Excess Fluid Volume describe signs or symptoms rather than causal factors.

The nurse receives the following report on four patients on the medical-surgical unit. Which patient will the nurse attend to first? a) Gait unsteady, uses walker, needs 2-person assist with ambulation b) Abdominal wound is draining foul-smelling fluid, incision margins are red, heart rate 100 beats/min c) Blood pressure 90/50 mm Hg, heart rate 40 beats/min, rates chest pain at 8 on a 0 to 10 pain scale d) Verbalizes history of migraine headaches, eyes closed during assessment interview

ANS: C Unstable vital signs with chest pain is of the highest priority because these symptoms may be life threatening. These instabilities must be addressed at once. Although an unsteady gait places a patient at risk for falls, this answer indicates that the patient uses a walker and 2-person assist. The draining wound is infected; however, this can be addressed with medications. Infections do not usually progress rapidly (i.e., as compared with chest pain). The wound symptoms are not immediately life threatening. A patient with a history of migraine headaches is not a priority at this time, although the patient's pain should be relieved as quickly as possible after dealing with the highest priority problem(s).

Which of the following describes the difference between a collaborative problem and a medical diagnosis? a) A collaborative problem is treated by the nurse; a physician is responsible for the treatment of a medical problem. b) A collaborative problem is a nursing diagnosis that requires specific orders from a physician; a medical diagnosis directs all nursing care. c) A collaborative problem has the potential to become an actual nursing diagnosis; a medical diagnosis rarely changes. d) A collaborative problem requires intervention by the nurse and physician or other professional; a medical diagnosis requires intervention by a physician.

ANS: D Collaborative problems are physiological complications for which a client may be at risk based on her medical diagnosis, medical treatment, or diagnostic studies. A collaborative problem requires monitoring by the nurse and intervention by a physician. A medical diagnosis requires interventions (medications, treatments) by the physician. Medical diagnoses do not direct all nursing care. Collaborative problems have the potential to become medical, not nursing, diagnoses.

Which of the following is the best example of a nursing diagnosis statement? a) Pain related to appendicitis b) Fractured left leg related to impaired mobility c) Impaired mobility related to fractured left leg d) Acute pain related to out of bed activities

ANS: D Each of these nursing diagnoses contains a problem and etiology. A problem describes the human response to a health problem and should be written in NANDA-I format. The etiology contains factors that cause or contribute to the problem and should direct nursing interventions. Acute pain is a nursing diagnosis because it is a human response to a health problem. The etiology, out of bed activities, is an example of a contributing factor that the nurse can direct and for which she can make nursing interventions. Pain related to appendicitis is not descriptive of pain nor is appendicitis a nursing etiology; it is a medical diagnosis. Fractured left leg is a medical diagnosis and cannot be used as a nursing diagnosis. Impaired mobility is not appropriate because a medical diagnosis is used in the etiology.

Which of the following describes the most important use of making a nursing diagnosis? Assume all are true. a) Differentiates the nurse's role from that of the physician b) Identifies a body of knowledge unique to nursing c) Helps nursing develop a more professional image d) Describes the client's needs for nursing care

ANS: D The benefits to nurses and nursing are that nursing diagnoses differentiate the nurse's role, they identify a unique body of nursing knowledge, and some think they help nursing to develop a more professional image. However, the primary goal of nursing is to serve the good of the patient. Therefore, the most important use of a diagnosis is to specifically identify the client's needs for quality nursing care.

When making a diagnosis using NANDA-I, which of the following provides support for the diagnostic label you choose? a) Etiology b) Related factors c) Diagnostic label d) Defining characteristics

ANS: D The defining characteristics are the signs and symptoms that must be present to support any given nursing diagnosis. The etiology and related factors are the causes of or contributing factors to the problem. The diagnostic label is the name NANDA-I has given the problem; it is chosen based on the presence of defining characteristics. ANS: 4, 2, 1, 3 In Maslow's hierarchy, physiological needs and safety are the highest priority. Sleep is a basic physiological need. Infection can threaten physical health. In this question, infection is not present; therefore, there is only a risk for it. Sleep Deprivation is an immediate problem that affects general physical, mental, and emotional health. Neither Anxiety nor Disturbed Body image is a physiological or safety need. Anxiety is a more immediate need than is Disturbed Body Image; therefore, it probably deserves a higher ranking. Remind students that the ranking would depend on the severity of each problem, which is not known by the labels alone.

The nurse documents in the progress notes: "Admitted to emergency department accompanied by wife. Patient is alert and oriented, blood pressure is 120/80 mm Hg, and pulse is 80 beats/min. The patient is anxious. He becomes nervous and when asked about his smoking history." Which statement from the nurse's note is the best example of an inference? a) Blood pressure reading 120/80 mm Hg b) Patient is accompanied by wife. c) Patient has a history of smoking. d) The patient is anxious.

ANS: D The inference in this item is that the patient is anxious. The nurse observes that the patient is nervous and shaky. She can document these observations but she cannot infer that these observations mean that the patient has anxiety. Blood pressure and patient accompaniment by wife are objective data. History of smoking is subjective data.

The client's weight is appropriate for his height. His laboratory values and other assessments reflect normal nutritional status. However, he has told the nurse, "I probably eat a little too much red meat. And what is this I hear about needing omega 3 oils in my diet? I don't like to take supplements, and I think I could really improve my nutrition." Which of the following nursing diagnoses should the nurse use? a) Balanced Nutrition b) Possible Imbalanced Nutrition: Less Than Body Requirements c) Risk for Imbalanced Nutrition: Less Than Body Requirements d) Readiness for Enhanced Nutrition

ANS: D You will use a wellness diagnosis when a person's present level of wellness is effective, and when the person wants to move to a higher level of wellness—in this case, a higher level of nutrition. The format for a wellness diagnosis is "Readiness for Enhanced. . . ." Use a possible diagnosis when you have enough data to suspect a problem but need more data to support a diagnosis. Use a risk diagnosis when there are risk factors for a problem.