24 Quiz 6 - The Nursing Process - Diagnosis

The nurse's initial responsibility in the management of a client's collaborative problem is to: 1. Monitor for changes 2. Advocate for the client 3. Implement interventions 4. Evaluate client outcomes

ANS: 1 Nurses initially monitor to detect the onset of changes in a client's status. Although advocating for the client is a nursing role, it is not reserved exclusively to collaborative problems. Implement interventions is not the initial responsibility. Evaluate client outcomes is not the initial responsibility.

The nurse is concerned that atelectasis may develop as a postoperative complication. Which of the following is an appropriate diagnostic label for this problem, should it occur? 1. Impaired gas exchange 2. Decreased cardiac output 3. Ineffective airway clearance 4. Impaired spontaneous ventilation

ANS: 1 A potential etiology for impaired gas exchange may be atelectasis. Atelectasis would not support the diagnostic label for decreased cardiac output. Atelectasis would not be an etiology for ineffective airway clearance. Increased tenacious sputum production would be a possible etiology for ineffective airway clearance. Impaired spontaneous ventilation would not be an appropriate diagnostic label for atelectasis.

Of the following statements, which one is an example of an appropriately written nursing diagnosis? 1. Diarrhea related to food intolerance 2. Alteration in comfort related to pain 3. Risk for impaired skin integrity related to poor hygiene habits 4. Potential complications related to insufficient vascular access

ANS: 1 Diarrhea related to food intolerance is a correctly written nursing diagnosis. It consists of a problem related to an etiology, and it is a condition that nursing interventions can treat or manage. Alteration in comfort related to pain is not written correctly because it is a circular statement. It would be appropriate to state ineffective breathing pattern related to incisional pain. Risk for impaired skin integrity related to poor hygiene habits is not written correctly because it uses a nurse's prejudicial judgment. It would be more appropriate and professional to state risk for impaired skin integrity related to knowledge about perineal care. Potential complications related to insufficient vascular access is not written appropriately because it identifies a nursing problem, not a client's problem. It would be appropriate to state risk for infection related to presence of invasive lines.

Which of the following is an appropriate etiology for a nursing diagnosis? 1. Incisional pain 2. Poor hygienic practices 3. Need to offer bedpan frequently 4. Inadequate prescription of medication

ANS: 1 Incisional pain is an appropriate etiology for a nursing diagnosis. It is a condition that identifies the cause of a client's response to a health problem, and a condition that a nurse can treat or manage. Poor hygiene practices would not be an appropriate etiology for a nursing diagnosis because it insinuates a nurse's prejudicial judgment. Need to offer bedpan frequently is not an appropriate etiology because it identifies a nursing intervention, not an etiology. Inadequate prescription of medication by the physician is not an appropriate etiology because it identifies the nurse's problem, not the client's problem. The nursing diagnosis should center attention on client needs.

The nurse has identified deficient knowledge regarding surgery for a client who is scheduled for an outpatient procedure. Which of the following instructional topics will best minimize the client's anxiety regarding the procedure? 1. Assure the client that preoperative sedation will be administered. 2. Discuss the pre- and postprocedure care that will be provided. 3. Provide a detailed explanation of why the procedure is necessary. 4. Guarantee that family will be regularly updated during the procedure.

ANS: 2 A nursing diagnosis focuses on a client's actual or potential response to a health problem rather than on the physiological event, complications, or disease. In the case of the diagnosis deficient knowledge regarding surgery, the nurse will best minimize anxiety by providing information regarding pre- and postoperative routines so as to facilitate the client in formulating realistic expectations. Although the other options are appropriate, they are limited in scope and do not have as much impact on anxiety.

The nurse uses nursing diagnoses after completion of the client assessment, because they: 1. Are required for accreditation purposes 2. Identify the domain and focus of nursing 3. Assist the nurse to distinguish medical from nursing problems 4. Make all client problems become more quickly and easily resolved

ANS: 2 After completing the client assessment, the nurse develops nursing diagnoses based on the data obtained. Nursing diagnoses distinguish the nurse's role from that of the physician, and nursing diagnoses help nurses to focus on the role of nursing in client care. Although most state nurse practice acts include nursing diagnosis as part of the domain of nursing practice, nursing diagnoses are not required for accreditation purposes. Medical problems are identified with medical diagnostic statements to treat a disease condition. Nursing diagnoses describe the client's actual or potential response to a health problem that the nurse is licensed and competent to treat. Nursing diagnoses distinguish the nurse's role from that of the physician. Nursing diagnoses may facilitate communication among health professionals, but they do not necessarily allow all client problems to become more quickly and easily resolved.

A client newly diagnosed with type 2 diabetes mellitus asks the nurse to explain, "what the diagnosis means." Which of the following rationales best supports the nurse's determination that the client has knowledge deficit rather than a readiness for enhanced knowledge? 1. The client initiated the question. 2. This is a new diagnosis for the client. 3. The client identified a lack of understanding. 4. Type 2 diabetes mellitus is a complicated disease process.

ANS: 2 Although all the options are accurate, "this is a new diagnosis for the client" best reflects the need for knowledge because the client had no previous experience with the condition and so had a true knowledge deficit.

The nursing diagnosis of acute pain falls under which of the following comfort domain classifications? 1. Social comfort 2. Physical comfort 3. Interpersonal comfort 4. Environmental comfort

ANS: 2 There are only three classifications for the comfort domain. Acute pain is a physiological response and so is classified as a physical comfort problem. Impaired verbal communication is considered a social comfort issue, while at risk for poisoning would be considered an environmental comfort issue.

Which of the following assessment findings best supports the nursing diagnosis of pain in right knee joint related to degenerative process? 1. Paternal family history of osteoarthritis has been reported. 2. Client is observed grimacing when walking to bathroom. 3. Right knee appears edematous when compared to left knee. 4. Client rated the pain felt after walking at a 6 on a scale of 1 to 10.

ANS: 2 To collect complete, relevant, and correct assessment data it helps to identify assessment activities that produce specific kinds of data. When possible, the nurse should collect objective data because they are often more supportive than subjective data. Observation of the client's response to the use of the affected joint is the most supportive of the options.

Which one of the following is a NANDA International nursing diagnosis label? 1. Frequent urination 2. Coughing and dyspnea 3. Risk for impaired parenting 4. Abnormal hygienic care practices

ANS: 3 "Frequent urination" is a symptom, not a NANDA International nursing diagnosis label. "Coughing and dyspnea" are symptoms, not a NANDA International nursing diagnosis label. "Risk for impaired parenting" is a NANDA International nursing diagnosis label. "Abnormal hygienic care practices" is not a NANDA International nursing diagnosis label. It incorrectly implies a nurse's prejudicial judgment.

When asked to define "Nursing Diagnosis" the nurse's best response is: 1. "It is the second step in the Nursing Process." 2. "It is the process of defining a client's problems." 3. "It correlates a client's problem with a condition a nurse is competent to treat." 4. "It focuses care a licensed nurse can provide with the identified needs of a client."

ANS: 3 "It correlates a client's problem with a condition a nurse is competent to treat" is a statement that describes the client's actual or potential response to a health problem that the nurse is licensed and competent to treat. Although "It is the second step in the Nursing Process" is true, it does not define the term. Although "It is the process of defining a client's problems" is true, is does not address the nursing aspect of the term. Although "It focuses care a licensed nurse can provide with the identified needs of a client" is true, the focus is not primarily on care.

A diagnostic error can influence the application of the nursing care plan. A likely source for a nursing diagnosis error is if the nurse: 1. Validates the assessment information in the data base 2. Uses the NANDA International list of diagnoses as a primary source 3. Formulates a diagnosis too closely resembling a medical diagnosis 4. Distinguishes the nursing focus instead of other health care disciplines

ANS: 3 A nursing diagnosis should identify the client's response, not the medical diagnosis. Because the medical diagnosis requires medical interventions, it is legally inadvisable to include it in the nursing diagnosis. A nurse should validate assessment data for accuracy and understanding. Using the NANDA International list of diagnoses as a source helps to ensure accuracy. One purpose the nursing diagnosis serves is to distinguish the nurse's role from that of the physician. Another purpose is to help nurses focus on the role of nursing in client care. Nursing diagnoses promote understanding between nurses regarding clients' health problems.

A nursing student expresses some confusion about identifying the appropriate nursing diagnosis for a specific client. Which of the following responses by the clinical instructor is most instructional? 1. "After defining the client's symptomatology, eliminate those nursing diagnoses that are not supported by the database." 2. "Assess your client and then select the nursing diagnosis that has the greatest number of observable defining characteristics." 3. "After assessing the client, compare their symptoms carefully to the defining characteristic of the nursing diagnosis in order to support or eliminate it as applicable." 4. "With experience you will become skilled at identifying the defining characteristics of a nursing diagnosis in your client. Until that time use a nursing diagnosis book to help in the selection process."

ANS: 3 After assessing the client, always examine the defining characteristics in your database carefully to support or eliminate a nursing diagnosis. Although the other options are correct, they do not provide as concise an explanation as "after assessing the client, compare their symptoms carefully to the defining characteristic of the nursing diagnosis in order to support or eliminate it as applicable."

Of the following statements, which one is an example of an appropriately written nursing diagnosis? 1. Anxiety related to cardiac monitor 2. Pain related to difficulty ambulating 3. Chronic pain related to insufficient use of medication 4. Bedpan required frequently as a result of altered elimination pattern

ANS: 3 Chronic pain related to insufficient use of medication is an example of an appropriately written nursing diagnosis. It consists of a diagnostic label and the associated etiology. Nursing interventions can be directed at treating or managing the behavior of insufficient medication use. Anxiety related to cardiac monitor is written incorrectly because it identifies the equipment rather than the client's response to the equipment. It would be appropriate to state deficient knowledge regarding the need for cardiac monitoring. Pain related to difficulty ambulating is not written correctly. What could be a defining characteristic is used as an etiology. This nursing diagnosis could be rewritten more appropriately as impaired mobility related to pain as evidenced by difficulty ambulating. Or it could be an inaccurate diagnostic label and could be rewritten as anxiety related to difficulty in ambulating. Bedpan required frequently as a result of altered elimination pattern is written incorrectly because it identifies a nursing intervention, not the client's problem. It could be reworded as diarrhea related to food intolerance.

Of the following statements, which one is an example of an appropriately written nursing diagnosis? 1. Risk for change in body image related to cancer 2. Cardiac output decreased related to motor vehicle accident 3. Ineffective airway clearance related to increased secretions 4. Potential for injury related to improper teaching in the use of crutches

ANS: 3 Ineffective airway clearance related to increased secretions is written appropriately. It identifies a problem using a NANDA International diagnostic statement and connects it to its etiology. Risk for change in body image related to cancer is written incorrectly. It uses a medical diagnosis for the etiology. Cardiac output decreased related to motor vehicle accident is written incorrectly. The etiology is not treatable. Potential for injury related to improper teaching in the use of crutches is written incorrectly. It identifies the nurse's problem, not the client's.

Which of the following statements made by a nursing student regarding the cultural characteristics of pain requires immediate follow-up by the clinical instructor? 1. "I can tell when my Hispanic clients are in pain." 2. "Moaning is a classic sign of pain in most cultures." 3. "All clients will tell you when they need pain medication." 4. "Chronic pain is difficult to manage especially for the stoic individual."

ANS: 3 Nurses who are not familiar with how a particular culture or developmental group expresses pain

Based on the following information, what would the nurse identify as the most appropriate nursing diagnosis? The client has abnormal breath sounds, dyspnea, an intermittent cough, and variable respiratory rate. 1. Risk for injury 2. Excess fluid volume 3. Ineffective airway clearance 4. Impaired spontaneous ventilation

ANS: 3 The defining characteristics of abnormal breath sounds, dyspnea, an intermittent cough, and variable respiratory rate cue the nurse to the nursing diagnosis of ineffective airway clearance. Risk for injury does not support the diagnostic label of risk for injury. Excess fluid volume does not support the diagnostic label of excess fluid volume. There would be other defining characteristics such as edema, weight gain, and an elevated blood pressure. Impaired spontaneous ventilation does not most accurately describe impaired spontaneous ventilation. Other characteristics, such as apnea, would better support the diagnostic label of impaired spontaneous ventilation.

Which of the following responses best reflects an understanding of the purpose of the "related to" phrase attached to the diagnostic label deficient knowledge regarding postoperative routines? 1. "To focus on the cause of the client's needs" 2. "To identify the etiology of the client's diagnosis" 3. "To provide for individualization of the nursing interventions" 4. "To communicate the client's deficits to the nursing staff"

ANS: 3 The inclusion of the "related to" phrase requires you to use critical thinking skills to individualize the nursing diagnosis and then select personalized nursing interventions. Although the other options are not incorrect, they do not reflect the best understanding of the purpose of the phrase, "To provide for individualization of the nursing interventions" is the correct answer.

A 53-year-old client is seen at the clinic for a yearly physical examination. In evaluating the client's weight, the nurse also considers the age and height. This is an example of: 1. Defining the client problem 2. Recognizing gaps in data assessment 3. Comparing data with normal health patterns 4. Drawing conclusions about the client's response

ANS: 3 The nurse uses scientific knowledge and experience to analyze and interpret data collected about the client. This includes comparing the data with norms. The nurse is comparing data to determine if there is a problem. A problem has not yet been identified. The nurse is not recognizing gaps in data assessment. An example of a gap in data assessment would be if the client's weight had not been measured. The nurse has not drawn a conclusion about the client's response. The nurse must first compare the data with normal health problems to be able to arrive at a conclusion.

The primary purpose of a nursing diagnosis, according to the nurses, is to: 1. Support the medical plan of care 2. Provide a standardized approach for all clients 3. Recognize the client's response to an illness or situation 4. Offer the nurse's subjective view of the client's behaviors

ANS: 3 The primary purpose of a nursing diagnosis is to recognize the client's response to an illness or situation. The nurse can then use the nursing diagnosis to select appropriate nursing interventions to achieve positive client outcomes. A nursing diagnosis is based on the client, not on the medical plan of care. Although nursing diagnoses may facilitate communication, it does not mean they provide a standardized approach for all clients. Nursing diagnoses are individualized to meet the client's needs. The primary purpose of nursing diagnoses is not to offer the nurse's subjective view of the client's behaviors. Nursing diagnoses are based on subjective and objective client data and should not include the nurse's w +++++++++++personal beliefs and values.'/

Of the following statements, which one is an example of an appropriately written nursing diagnosis? 1. Acute pain related to left mastectomy 2. Impaired gas exchange related to altered blood gases 3. Deficient knowledge related to need for cardiac catheterization 4. Need for high protein diet related to alteration in client nutrition

ANS: 3 This nursing diagnosis is written correctly. It defines a problem and its etiology. In this case the problem is the client's response to a diagnostic test. A medical diagnosis should not be recorded as the etiology because nursing interventions cannot change the medical diagnosis. It would be appropriate to state acute pain related to impaired skin integrity secondary to mastectomy incision. This nursing diagnosis is written incorrectly because it uses supportive data of the problem as the etiology. This nursing diagnosis does not identify the problem and etiology. It identifies the client's goal rather than the problem. It could be reworded as imbalanced nutrition: less than body requirements related to inadequate protein intake.

The nurse has diagnosed the client's problem as altered elimination. From the database the nurse identifies all the following as appropriate etiologies for this diagnosis except: 1. Poor fiber intake 2. Limited fluid intake 3. Total hip replacement 4. Lower abdominal discomfort

ANS: 3 Total hip replacement because the medical diagnosis requires medical interventions, it is legally inadvisable to use it in the nursing diagnosis. Rather, the nurse should identify the client's response, such as decreased mobility. The nurse should be able to provide nursing interventions that will treat the etiology. Poor fiber intake would be an appropriate etiology for the problem of altered elimination. Limited fluid intake would be an appropriate etiology for the nursing diagnosis of altered elimination. Lower abdominal discomfort is an appropriate etiology for the nursing diagnosis of altered elimination.

Identify the defining characteristics in the following nursing diagnosis: Altered speech related to recent neurological disturbance, as evidenced by inability to speak in complete sentences. 1. "Altered speech" 2. "As evidenced by" 3. "Recent neurological disturbances" 4. "Inability to speak in complete sentences"

ANS: 4 Defining characteristics are assessment findings that support the nursing diagnosis. In this example, the inability to speak in complete sentences supports the nursing diagnosis of altered speech. "Altered speech" is the diagnostic label identifying the problem. "As evidenced by" is a connecting statement for the problem and the defining characteristics. "Recent neurological disturbances" is the etiology.

When asked to define the purpose of diagnostic reasoning, the best nursing response is: 1. "Diagnostic reasoning is the foundation of the second step of the nursing process; Nursing Diagnosis." 2. "The diagnostic reasoning process flows from the assessment process and includes decision-making steps." 3. "Diagnostic reasoning includes data clustering, identifying client needs and formulating the diagnosis or problem." 4. "Diagnostic reasoning involves using the assessment collected on a specific client to logically arrive at an appropriate nursing diagnosis."

ANS: 4 Diagnostic reasoning is a process of using the assessment data gathered about a client to logically explain a clinical judgment, in this case a nursing diagnosis. The remaining options do not describe purpose but rather identify outcomes of diagnostic reasoning.

Which one of the following is an appropriate etiology for a nursing diagnosis? 1. Myocardial infarction 2. Cardiac catheterization 3. Abnormal blood gas levels 4. Increased airway secretions

ANS: 4 Increased airway secretions is a condition that responds to nursing interventions and therefore would be an appropriate etiology for a nursing diagnosis. Myocardial infarction would not be an appropriate etiology for a nursing diagnosis because it is a medical diagnosis. Nursing interventions will not alter the medical diagnosis of myocardial infarction. Cardiac catheterization is a diagnostic procedure and would not be an appropriate etiology for a nursing diagnosis. Rather, the client's response to the procedure would be the area of nursing concern. Abnormal blood gas levels would not be an appropriate etiology for a nursing diagnosis because it is not a causative factor, but rather it is a defining characteristic of a problem.

The nurse recognizes that which one of the following statements is true with regard to the formulation of nursing diagnoses? 1. The diagnosis should identify a "cause and effect" relationship. 2. The diagnosis must remain constant during the client's hospitalization. 3. The etiology of the diagnosis must be within the scope of the health care team's practice. 4. The diagnosis should include the problem and the related contributing conditions.

ANS: 4 The diagnosis should include the problem and the related contributing conditions is a true statement. Related factors are causative or other contributing conditions that have influenced the client's actual or potential response to the health problem and can be changed by nursing interventions. The nursing diagnosis does not identify a "cause and effect" relationship; rather, it indicates that the etiology contributes to or is associated with the client's problem. The nursing diagnosis does not have to remain constant during the client's hospitalization. It should change according to changes in the patient. The etiology or cause of the nursing diagnosis must be within the domain of nursing practice and a condition that responds to nursing interventions, not those of the entire health care team.