PrepU Chapter 5: Analyzing Data to Make Informed Clinical Judgment

The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse? a. Have the UAP retake the blood pressure b. Notify the physician c. Recheck blood pressure in 30 minutes d. Reassess blood pressure

d. Reassess blood pressure The nurse can delegate the monitoring and documenting of specific assessments to UAPs; but the nurse always retain the responsibility to interpret delegated assessment data to evaluate the client's condition. The nurse should retake the blood pressure immediately as it is abnormally low for this client. Having the UAP retake the blood pressure does not allow the nurse to evaluate the client or assess the accuracy of the UAP's ability to take a blood pressure. The physician should not be notified until the blood presser has been reassessed.

One characteristic of a nurse who is a critical thinker is the ability to a. form an opinion quickly b. offer advice to clients. c. be right most of the time. d. validate information and judgments.

d. validate information and judgments. One characteristic of a critical thinker is the ability to validate information and judgments with experts in the field.

A nurse has been clustering the data collected during the initial assessment of a frail elderly client. When making inferences about the data clusters, the nurse is unsure whether to associate a cluster of data with a nursing diagnosis or with a collaborative problem. What question would best guide the nurse's decision? a. "Does this issue require medical intervention?" b. "Is this problem acute or is it chronic?" c. "Can this issue be addressed on an outpatient basis?" d. "Can an unlicensed care provider meet this person's needs?"

a. "Does this issue require medical intervention?" Collaborative problems are defined as "certain physiological complications that nurses monitor to detect their onset or changes in status; nurses manage collaborative problems using physician-prescribed and nursing-prescribed interventions to minimize the complications of events." In other words, medical treatment is needed in addition to nursing care. Questions around unlicensed care, chronic versus acute course of illness and outpatient care do not differentiate between nursing diagnoses and collaborative problems.

The nurse receives a report on a group of clients. What client statement requires further clarification to ensure client safety? Select all that apply. a. "I do not usually take insulin." b. "This looks like a new pill." c. "My daughter will be visiting today." d. "I feel much better today." e. "I fell at home last month."

a. "I do not usually take insulin." b. "This looks like a new pill." e. "I fell at home last month." The nurse should always validate data (allergies, medications, recent injuries, or signs and symptoms) and evaluate client cues (abnormal and supportive). Inadequate, unreliable, or invalid data can lead to client harm. The nurse needs to appropriately identify abnormal cues such as "I do not usually take insulin," "this looks like a new pill," or "I fell at home last month" in order to prevent client injury. The nurse would verify why the client is now receiving insulin and explain the reason for the treatment to the client. If a client does not recognize a medication, the nurse should verify that the medication has been prescribed for the client and again explain the reason for the new medication. Clients who have fallen in the past are at higher risk for falling again. The nurse should ensure that there is documentation stating the client is at risk for falls and implement measures to keep the client safe. A family member visiting has no bearing on ensuring safety. The fact that the client's condition is improving is good; it does not place the client at risk for injury.

A client asks why a nurse measured the blood pressure after the nursing assistant completed the measurement a few minutes ago. What should the nurse respond to the client? a. "It was done to validate the reading." b. "The first reading was measured too early." c. "The nursing assistant had difficulty with the reading." d. "The second reading was used as a guide for providing a medication."

a. "It was done to validate the reading." The second reading was to verify the data with another health care professional. A blood pressure measurement is not done "too early." Saying that the nursing assistant had difficulty with the reading could cause the client to be alarmed or to question the nursing assistant's ability to provide care. Some medication may require a blood pressure measurement however this is unlikely considering the timing of the measurements.

A community health nurse provides information to a client with newly diagnosed multiple sclerosis for a support group at the local hospital for clients diagnosed with multiple sclerosis and their families. Providing this information is an example of which of the following? a. A referral b. A consultation c. Conferring d. Reporting

a. A referral Referring is the process of sending or guiding the client to another source for assistance. Consultation is the process of inviting another professional to evaluate the client and make recommendations to you about his or her treatment. Conferring is to consult with someone to exchange ideas or seek information, advice, or instructions. Reporting is the oral, written, or computer-based communication of client data to others.

The nurse formulates a nursing diagnosis of pain, acute, from assessment data collected from a client who has complained of pain of a 7 (1 to 10 scale). What type of nursing diagnosis would this be considered? a. Actual Nursing Diagnosis b. Risk Nursing Diagnosis c. Wellness Nursing Diagnosis d. Rule Out Nursing Diagnosis

a. Actual Nursing Diagnosis This client is having an actual problem--pain--which therefore would be classified as an actual nursing diagnosis and provides a description of the problem that the client is currently having.

The nursing instructor tells the students that in order to develop critical thinking skills there are some essential elements that must be obtained. What elements does the student need? (Select all that apply.) a. Be nonjudgmental and keep an open mind. b. Only validate data that you see, not what the client tells you. c. Use rationale to support opinions or decisions. d. Do not reflect on your thoughts, just make a decision. e. Acquire an adequate knowledge base that continues to build.

a. Be nonjudgmental and keep an open mind. c. Use rationale to support opinions or decisions. e. Acquire an adequate knowledge base that continues to build. The essential elements of critical thinking are: Keep an open mind, use rationale to support opinions or decisions, reflect on thoughts before reaching a conclusion, use past clinical experiences to build knowledge, acquire an adequate knowledge base that continues to build, be aware of the interactions of others, and be aware of the environment.

What can the nurse use to learn new information and add to their knowledge base? a. Clinical experience. b. Past experience of other nurses. c. Reading a medical-surgical textbook. d. Doing several written care plans

a. Clinical experience. The critical thinker uses each clinical experience to learn new information and to add to the knowledge base. Another important aspect of critical thinking involves awareness of human interactions and the environment, which provides cues and directly influence decisions and judgments.

The nurse recognizes the following to be a necessary component of performing an accurate assessment. (Select all that apply.) a. Collection and organization of data b. Validation of data c. Inaccurate data d. Documentation of data e. Incomplete data

a. Collection and organization of data b. Validation of data d. Documentation of data Before beginning to analyze data, the nurse must make sure the assessment is accurately performed, which includes collection and organization, validation, and documentation of the data. The nurse does not want to include any inaccurate or incomplete data--doing so will lead to a faulty assessment.

The nurse reviews data collected during an assessment. Which data should the nurse validate? Select all that apply. a. Data that is inconsistent with another finding b. Subjective and objective data are inconsistent c. Respiratory rate slower during sleep than while awake d. Evening temperature higher than morning temperature e. Gap between what the client said and what is in the medical record

a. Data that is inconsistent with another finding b. Subjective and objective data are inconsistent e. Gap between what the client said and what is in the medical record Conditions in which data should be validated include findings that are abnormal or are inconsistent with other findings, discrepancy between subjective and objected data collected, and a gap between what the client says now versus what was said or documented in the past. Vital signs do not need to be validated unless there is a huge discrepancy. Respiratory rates are slower during sleep. Body temperature peaks in the evening.

The nurse educator is teaching nursing students about critical thinking to ensure appropriate clinical judgments. Which of the following should the nurse educator include in this teaching session? Select all that apply. a. Use rationale and research to support decisions. b. Base decisions solely on clinical and educational experiences. c. Reflect on past experiences and thoughts before reaching a conclusion. d. Keep an open mind and listen to what others have to say before making a decision. e. Acquire an adequate knowledge base from ongoing education and professional journals.

a. Use rationale and research to support decisions. c. Reflect on past experiences and thoughts before reaching a conclusion. d. Keep an open mind and listen to what others have to say before making a decision. e. Acquire an adequate knowledge base from ongoing education and professional journals. Critical thinking is essential when making clinical judgments. In order to make good clinical judgments, the nurse needs to be open-minded and listen to what others have to say before making a decision; use rationale and research to support decisions; reflect on past experiences before reaching a decision; and maintain adequate knowledge in the field of expertise by way of continued education and reading professional journals. Decisions should not be based solely on the nurse's clinical and educational experiences; other, more experienced nurses may have more insight into the problem at hand.

The nurse has completed an assessment on a new client. After gathering the data, formulating a nursing diagnosis, and developing a plan of care, it is important for the nurse, before finalizing the plan, to a. discuss the plan with the client b. get physician orders to implement the plan c. set goals for the client d. document the plan on the cardex for all to utilize

a. discuss the plan with the client Sharing the assessment and plan with the client will allow the client to offer his or her opinion, concerns, and willingness to proceed with the interventions. This makes the client an active participant in his or her plan of care.

A nursing student is learning how to use critical thinking in formulating a plan of care. The student understands which of the following to be things needed to demonstrate that the process of thinking critically has begun? (Select all that apply.) a. explores other alternatives before making a decision b. disregards literature and sound rationale when looking to support own opinion c. uses past knowledge and experience to analyze data d. reserves a final opinion until further collecting data

a. explores other alternatives before making a decision b. disregards literature and sound rationale when looking to support own opinion d. reserves a final opinion until further collecting data Nurses can assess their critical thinking skills by asking themselves some of the following questions: do you reserve your final opinion until you have collected more or all of the information? Do you support your opinion with supporting data, sound rationale, and literature? Do you explore other alternatives before making a decision? Can you distinguish fact, opinion, and inference? Do you ask your client for more information or clarification when you do not understand? These are only a few questions nurses should ask when learning critical thinking skills. Disregarding the literature and sound rationale is not advisable.

The nurse is determining a priority problem that would be appropriate for a client with heart failure. Which problem would have the highest priority for the client? a. weight gain of 3 pounds (1.5 kilograms) over 1-2 days b. behind schedule on recommended screening mammograms c. knowledge deficiency related to lack of information regarding low-sodium diet d. coping impairment about hospitalization

a. weight gain of 3 pounds (1.5 kilograms) over 1-2 days Nursing diagnoses are based on alterations in body system processes, lifestyle, personal issues, and specific causes. For the client with heart failure, the problem that would have the highest priority would be the weight gain of 3 pounds (1.5 kilograms) over 1-2 days. This change can be related to a decline in cardiac functioning and needs to be addressed first. Once this priority problem has been investigated, other problems can be addressed. Ineffective health maintenance, such as being behind schedule on recommended screening mammograms, can be addressed last. Knowledge deficiency related to a lack of information regarding a low-sodium diet would be the next in priority because learning how to reduce sodium could help control the heart failure. Coping impairment about hospitalization would be addressed after the knowledge deficiency.

A nursing student is explaining to a roommate the relationship between diagnostic reasoning and critical thinking. Which of the following is the correct statement for the nursing student to make? a. "Critical thinking is a form of diagnostic reasoning used to interpret data correctly." b. "Diagnostic reasoning is a form of critical thinking used to interpret data correctly." c. "Critical thinking and diagnostic reasoning are not related." d. "Diagnostic reasoning is used in assessment, whereas critical thinking is used in analysis."

b. "Diagnostic reasoning is a form of critical thinking used to interpret data correctly." As the second step or phase of the nursing process, data analysis is a very difficult step because the nurse is required to use diagnostic reasoning skills to interpret data accurately. Diagnostic reasoning is a form of critical thinking.

A nurse is preparing to document conclusions after analyzing data and includes information about related factors and manifestations. What is the nurse formulating? a. Risk nursing diagnosis b. Actual nursing diagnosis c. Collaborative problem d. Problem for referral

b. Actual nursing diagnosis An actual nursing diagnosis includes information about related factors with the statement "related to." A risk nursing diagnosis, collaborative problem, or problem for referral does not include manifestations.

A nurse has completed a comprehensive assessment of a client and has begun the process of data analysis. Data analysis should allow the nurse to produce which direct result? a. Outcomes evaluation b. Nursing diagnoses c. Holistic interventions d. An interdisciplinary plan of care

b. Nursing diagnoses The end result of data analysis is the identification of a nursing diagnosis, collaborative problem, or need for referral to another health care professional. After nursing diagnoses are identified, then outcomes, planning, implementation, and evaluation occur.

A nurse has completed data analysis. Which of the following would the nurse identify first as the result? a. Outcome evaluation b. Nursing diagnosis c. Interventions d. Plan of care

b. Nursing diagnosis The end result of data analysis is the identification of a nursing diagnosis, collaborative problem, or need for referral to another health care professional. After nursing diagnoses are identified, then outcomes, planning, implementation, and evaluation occur.

After completing the diagnostic reasoning process, the nurse documents a wellness diagnosis. Which of the following would the nurse have most likely identified? a. Potential weaknesses b. Strengths c. Abnormal findings d. Potential complication

b. Strengths Identified strengths are used in formulating wellness diagnoses. Potential weaknesses are used in formulating risk diagnoses. Abnormal findings are used in formulating actual nursing diagnoses. Potential complications are commonly documented as collaborative problems.

Which of the following statements is true of nursing diagnoses? a. They are rooted in subjective rather than objective data. b. They focus on the responses of clients to health problems and events. c. They are less specific but more holistic than medical diagnoses. d. They encompass psychological rather than physiological problems.

b. They focus on the responses of clients to health problems and events. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems and life processes. They are not solely psychologically based, nor are they necessarily less specific than medical diagnoses. They are based on both subjective and objective data.

A nursing student demonstrates understanding of the different types of nursing diagnoses when choosing which of the following to be an actual diagnosis? a. risk for impaired skin integrity b. impaired skin integrity c. readiness for enhanced skin integrity d. risk for infection

b. impaired skin integrity Risk for impaired skin integrity and risk for infection are both "risk for" diagnoses, while readiness for enhanced skin integrity is a wellness diagnosis. The only actual diagnosis is impaired skin integrity.

A client who is 2 days postoperative reports pain and requests pain medication. After assessing the client's pain level, the nurse decides to give the client oral oxycodone hydrochloride-acetaminophen instead of intravenous morphine. This nurse is doing which step of the nursing process? a. assessment b. implementation c. evaluation d. diagnosis

b. implementation This step is implementation, because the nurse is taking appropriate action by giving oral medication. Assessment is the first step of the nursing process when the nurse collects data. Diagnosis is determining the problem. Evaluation is the final step to see if client has achieved established goals.

A nurse is working with a client who has a history of chronic obstructive pulmonary disease (COPD). While bathing the client, the nurse senses that something is not quite right and takes the client's vital signs and obtains an oxygen saturation reading. The nurse is acting on which of the following? a. scientific rationale b. intuition c. knowledge d. prior history

b. intuition The nurse is acting on intuition, in this case, the feeling that something is not quite right. Scientific rationale is an explanation based on science. Knowledge is based on science and theories that the nurse learned in school. Prior history of the client is not what the nurse is acting upon in this case.

A client with diabetes is admitted to the medical unit for the fifth time in 6 months because of elevated blood glucose level. The nurse caring for the client immediately states, "I knew she would be back. It was just a matter of time. She is so noncompliant." This is an example of which of the following? a. clustering unrelated clues b. not hypothesizing several diagnoses c. taking too much time to process data d. learning what is going on with the client

b. not hypothesizing several diagnoses Nurses need to increase their diagnostic accuracy. Pitfalls decrease the reliability of cues and diagnostic accuracy. One pitfall is too many or too few data, unreliable data, and insufficient cues available. Other pitfalls are cues may be clustered yet unrelated. Another error is quickly diagnosing without hypothesizing. In this case the nurse states the client is noncompliant because the same problem is recurring, but in actuality the client may not have the sufficient knowledge or the means or funds to control the blood glucose level.

The nursing student demonstrates understanding of the different types of client problems when he identifies which of the following to be a collaborative problem? a. deficient knowledge b. risk for complication: pneumothorax c. risk for loneliness d. body image disturbance

b. risk for complication: pneumothorax Risk for loneliness, deficient knowledge, and body image disturbance all are problems that the nurse can intervene and treat independently. Risk for developing a pneumothorax is a collaborative problem that must be treated through physician interventions as well as nursing interventions.

The nurse collects data from a client with a nonproductive cough and labored respirations at a rate of 24/minute. What other data should the nurse collect before formulating an appropriate nursing diagnosis? a. history of illness b. status of breath sounds c. rash on face d. list of present medications

b. status of breath sounds Certain cues are pointing toward a respiratory problem for this client; however, no data have been gathered on breath sounds, which needs to be done before formulating an appropriate nursing diagnosis. The rash on face, present medications, and previous illnesses do not support cues to help in formulating a diagnosis for the breathing problem.

The new graduate nurse asks the preceptor, "I keep hearing about learning to develop good critical thinking skills, but don't really understand what that is?" What is the best response by the preceptor? a. "A way to think so that you can solve problems." b. "A way of problem solving so that you can transform from a novice to expert nurse." c. "A way of processing information using to formulate conclusions or diagnoses." d. "Being open-minded in order to provide professional nursing care."

c. "A way of processing information using to formulate conclusions or diagnoses." Critical thinking is the way in which the nurse processes information using knowledge, past experiences, intuition, and cognitive abilities to formulate conclusions or diagnoses.

The nurse has completed a plan of care for a client having a total knee replacement. In order to develop goals which are realistic for the client, what should the nurse do prior to implementing the plan? a. Discuss the plan of care with all of the health care providers involved. b. Share the assessment and plan with the client's primary health care provider. c. Ask the client for opinions and willingness to proceed with the interventions. d. Identify the needs of the client's family in relation to the priority problem.

c. Ask the client for opinions and willingness to proceed with the interventions. The plan of care should be agreeable to the client. Before finalizing the plan, it is important for the nurse to share the information with the client and seek out opinions and willingness to proceed with the interventions. Although discussing the plan of care with the all health care providers involved, involving the client in the process is the only way to know if the goals are realistic for his unique needs. Sharing the assessment and plan of care with the client's primary health care provider will only be necessary once the client has voiced his opinion and willingness to proceed with the interventions. The client's family should be involved in the plan of care and likely serve to make it more effective. The client must agree first and demonstrate willingness prior to discussing it with the family.

A nursing instructor is describing why data analysis is considered a very difficult step in the nursing process. Which of the following would the instructor identify? a. Abnormal data must be identified. b. It ends a decision about a nursing diagnosis. c. It requires diagnostic reasoning skills. d. Conclusions must be documented.

c. It requires diagnostic reasoning skills. Data analysis is a very difficult step because the nurse is required to use diagnostic reasoning skills to interpret data accurately. Although abnormal data must be identified, nursing diagnoses developed, and conclusions documented, these are not the reasons for why data analysis is a difficult step.

A nurse has identified the personal goal of developing critical thinking skills. In order to facilitate this goal, what action should the nurse prioritize? a. Maintaining a stable and static knowledge base b. Applying quick decision-making c. Maintaining an open mind d. Seeking new experiences

c. Maintaining an open mind To think critically, a nurse needs to keep an open mind, explore alternatives, use sound rationales, and avoid hurried decisions. The critical thinker also uses each clinical experience to learn new information and to add to his or her knowledge base. The accumulation of new experiences does not necessarily result in improved critical thinking.

The nurse enters an unassigned client's room to investigate an alarm. The client's intravenous (IV) bag is empty and the IV bag on the pole, left by the client's assigned nurse to hang next, is a different solution. What is the nurse's best action? a. Hang the IV solution the client's assigned nurse left on the pole. b. Obtain an IV bag of the current solution and hang it. c. Review the client's prescribed medication orders. d. Discontinue the current solution and disconnect it from the client.

c. Review the client's prescribed medication orders. The nurse should review the client's current orders to confirm which IV solution should be infused. Hanging the IV bag that was left on the pole is assuming that the assigned nurse hung the correct IV solution. Nurses should always verify orders themselves. Obtaining a bag of the current IV solution to hang is assuming, rather than verifying, as well. Discontinuing the solution is not necessary while verifying the orders.

An instructor is describing the steps of the diagnostic reasoning process to a group of students. The instructor is accurate when describing clustering data as involving which of the following? a. Hypothesizing of any potentially applicable wellness diagnoses, risk diagnoses, and actual diagnoses b. Documentation of all professional judgments along with any data that support those judgments c. The looking at of the identified abnormal findings and strengths for cues that are related d. Evaluation of both subjective and objective data to identify strengths and abnormal findings

c. The looking at of the identified abnormal findings and strengths for cues that are related In step two, clustering data, the nurse looks as the identified abnormal findings and strengths for cues that may be related. Hypothesizing any potentially applicable nursing diagnoses occurs in step four, propose possible nursing diagnoses. Documentation occurs in step seven, documenting conclusions. Analyzing subjective and objective data occurs in step one.

After collecting subjective and objective data for the admission database, what is the nurse's next action? a. Set nurse-driven goals for the client. b. Evaluate effectiveness of nursing actions. c. Validate the client's identified problems. d. Discuss the action plan with the client.

c. Validate the client's identified problems. The nurse should develop a plan of care while adhering to the nursing process. After assessment, the client's problems should be validated. Mutual goal setting is recommended versus nurse-driven goal setting. Nursing actions should not be implemented before the plan of care is developed. The plan of care can not be completed until the client's problems are validated and mutual goals are set.

The nurse is working with a 14-year-old girl who has told the nurse that she would like to try getting to bed a little sooner to get a full night's sleep and have more energy at school. The nurse diagnoses her with the following: Readiness for enhanced sleep related to client's expressed desire to go to bed earlier. Which type of nursing diagnosis is this? a. Actual b. Risk c. Wellness d. Syndrome

c. Wellness Health promotion diagnoses represent those situations in which the client does not have a problem but is at a point at which a higher level of health can be attained. In other words, this client has the desire to increase her well-being and actualize her human potential. This type of diagnosis is often worded readiness for enhanced. It indicates an opportunity to make greater, to increase quality of, or to attain the most desired level of function in the area of the diagnostic category. The other answers clearly do not describe this diagnosis.

A client who is overweight tells the nurse that he wants to lose weight but he doesn't know the best way to begin. The client states that he participates in routine exercise, but wants to increase the intensity of his workout. Which type of nursing diagnosis should the nurse choose for this client based on this information? a. Collaborative problem b. Risk diagnosis c. Wellness diagnosis d. Referral to dietitian

c. Wellness diagnosis A wellness diagnosis indicates that the client is ready to make changes to enhance his healthy state. The client states that he wants to lose weight and increase his exercise routine. A collaborative problem is one that suggests the need for both medical and nursing interventions to resolve the problem. A risk diagnosis indicates that the client does not currently have the problem but is at high risk for developing it. A referral, in which the nurse connects the client with other professionals and resources, is not necessary unless the nurse cannot assist the client with his needs.

The nursing instructor realizes that the nursing student understands all the criteria necessary for developing expertise when making clinical professional judgments by identifying the following as being a barrier to diagnostic reasoning. a. knowledge b. experience c. time d. practice e. seeing things as only right or wrong

e. seeing things as only right or wrong Developing expertise with making professional judgments comes with accumulation of both knowledge and experience. It is a process that develops over time and with practice. Seeing things as only right or wrong does not allow for seeing things as gray and may make you miss the bigger picture.

During the assessment interview, the client made numerous statements that suggested his life generally exists in a state of harmony and balance. The nurse would document this as which type of nursing diagnosis? a. Actual nursing diagnosis b. Risk nursing diagnosis c. Collaborative problem d. Health promotion diagnosis

d. Health promotion diagnosis A health promotion diagnosis indicates that the client has the opportunity for enhancement of a health state. The client is in a state of harmony and balance. An actual diagnosis would be used for a stated health problem. A risk diagnosis is used when a client does not currently have a problem but is at high risk for developing it. A collaborative problem is one that requires both medical and nursing interventions.

A nurse provided dietary counsel for a client who recently immigrated to the United States from Japan. During the initial interview, the client had his eyes lowered and did not make eye contact with the nurse. In analysis of the data, the nurse wrote down the following hunch: "risk for imbalanced nutrition related to client's unwillingness to listen to dietary advice." At the next meeting with the client a month later, however, the nurse was surprised to find that the client had adopted all recommended changes from their initial interview. Which error did the nurse commit in this case? a. Clustering together unrelated cues b. Diagnosing a client without hypothesizing several diagnoses c. Incorrectly wording a diagnostic statement d. Overlooking consideration of the clients cultural background

d. Overlooking consideration of the clients cultural background The nurse erred in this case by interpreting the lack of eye contact on the part of the client as an unwillingness to listen to recommendations. In some cultures, including Japanese, eye contact is not considered appropriate in certain social situations. The other errors listed do not apply in this case, as the nurse did not cluster together unrelated cues, diagnose the client without hypothesizing several diagnoses, or incorrectly word a diagnostic statement.

The nursing student has learned that diagnostic reasoning has several pitfalls. The second set of pitfalls usually occurs during the analysis phase and involves which of the following? a. too much data b. too few data c. invalid data d. cues that are clustered yet unrelated

d. cues that are clustered yet unrelated The second set of identified pitfalls occurs during the analysis phase. Cues may be clustered yet unrelated to each other. For example the client may be quiet and withdrawn, and the nurse may assume that the client is grieving because her husband recently died. But the client may be just fatigued from all the diagnostic tests she had just undergone. Too much, too few, and invalid data are pitfalls that can occur during the assessment, not the analysis, phase.

A nursing student demonstrates understanding of the different types of nursing problems when choosing the following to indicate that the client has the opportunity for an enhanced health state: a. risk diagnosis b. actual diagnosis c. medical diagnosis d. wellness diagnosis

d. wellness diagnosis A wellness diagnosis indicates that the client has the opportunity for enhancement of a health state. A risk diagnosis indicates that the client does not currently have the problem, but is at high risk for developing it. An actual diagnosis indicates that the client is currently experiencing the stated problem or has a dysfunctional pattern. A medical diagnosis is treated by the physician and is usually stated as a disease process.