Chapter 12: Diagnosing
A nurse is using Gordon's functional health patterns as an organizing framework for client assessment. The client has significant problems related to breathing for which the nurse identifies several nursing diagnostic labels, including ineffective breathing pattern and impaired gas exchange. The nurse understands that these nursing diagnoses would be organized under which functional pattern? Activity-exercise Nutritional-metabolic Coping-stress tolerance Congnitive-perceptual.
Activity-exercise Nursing diagnoses involving ineffective breathing pattern and impaired gas exchange would be organized under the pattern of activity-exercise. Nutritional-metabolic involves nursing diagnoses associate with weight, eating, fluids, and skin and tissue integrity. Coping-stress tolerance addresses coping, resilience, suicide, and self-mutilation. Cognitive-perceptual addresses pain, neurologic issues, impulse control, knowledge, and decision-making.
After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type? Wellness Actual Risk Possible
Actual "Ineffective Airway Clearance related to thick tracheobronchial secretions" is an actual diagnosis because it describes a human response to a health problem that is being manifested. A wellness diagnosis is a diagnostic statement that describes the human response to levels of wellness in an individual, family, or community that has a potential for enhancement to a higher state. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. A possible nursing diagnosis is made when not enough evidence supports the presence of the problem, but the nurse concludes that it is highly probable and wants to collect more information.
"Acute Pain related to instillation of peritoneal dialysate as evidenced by client wincing and grimacing during procedure, client description of experience as 'stabbing'" is an example of which type of nursing diagnosis? Actual diagnosis Risk diagnosis Wellness diagnosis Potential diagnosis
Actual diagnosis This is an actual diagnosis as it contains the diagnostic label (acute pain), related factors (instillation of peritoneal dialysate), and defining characteristics (wincing, grimacing during procedure, stabbing). Risk Diagnosis is a two-part statement that includes diagnostic label and risk factors. Wellness diagnosis is one-part statement that includes diagnostic label. Potential diagnosis is a two-part statement that includes diagnostic label and unknown related factors.
A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination? Bowel Incontinence Ulcerative Colitis Irritable Bowel Syndrome Small Bowel Obstruction
Bowel Incontinence Bowel incontinence is a NANDA-I-approved nursing diagnosis under the domain of Elimination. Ulcerative colitis, irritable bowel syndrome, and small bowel obstruction are medical diagnoses.
A 57 year-old woman is caring for her 84-year-old mother-in-law. Which statement would lead the nurse to make a nursing diagnosis of caregiver role strain? "I just don't have time to take a shower." "I feel great but wish that I could get more sleep." "My mother-in-law and I go for a walk daily." "My mother-in-law makes dinner on Tuesday's and I cannot stand her cooking."
"I just don't have time to take a shower." Any of these choices could be a clue to caregiver role strain when clustered with other evidence. However, the inability to care for one self strongly indicates that this client is not coping well.
A nursing diagnosis has which parts? Select all that apply. Risk factors Defining characteristics Related factors Chief complaint Descriptors Definition
-Defining characteristics - Related factors -Descriptors -Definition Defining characteristics are the observable "cues or inferences that cluster as manifestations of an actual illness or wellness health state." (NANDA, 2009). Related factors describe the condition, circumstances, or etiologies that contribute to the problem. Descriptors are words used to give additional meaning to a nursing diagnosis. Each approved NANDA-I nursing diagnosis has a definition that describes the characteristics of the human response under consideration. Rick factors describe the clinical cues in risk nursing diagnoses and are not used in actual nursing diagnosis.
A nursing diagnosis of Ineffective Airway Clearance has been chosen by the nurse caring for a client with respiratory problems. Which assessment data would be appropriate evidence of this diagnosis? Select all that apply. Ineffective cough Wheezes auscultated over all lung fields Labored respirations Viral pneumonia Oxygen at 3 liters/min per nasal cannula
-Ineffective cough -Wheezes auscultated over all lung fields -Labored respirations An ineffective cough, abnormal breath sounds, and labored respirations are all indications of ineffective airway clearance. Viral pneumonia is a medical diagnosis. Oxygen being administered per nasal cannula is a treatment for respiratory problems.
A nurse is planning a class for hospital nurses on the use of nursing diagnoses in client care. When discussing possible arguments that have been made against the use of nursing diagnoses, what information will the nurse include? Select all that apply. Nursing diagnoses apply limits to nursing practice. Nursing diagnoses discourage innovative thinking. Nursing diagnoses focus on negative client factors. Nursing diagnoses promote a paternalistic attitude from health care providers. Nursing diagnoses are confused with medical diagnoses in the health care community.
-Nursing diagnoses apply limits to nursing practice. -Nursing diagnoses discourage innovative thinking. -Nursing diagnoses focus on negative client factors. -Nursing diagnoses promote a paternalistic attitude from health care providers. Arguments against using nursing diagnoses include some nurses' beliefs that nursing diagnoses promote a standardized method of care with little thought to client's individual needs. Nursing diagnoses do focus on the client's deficits and not their strengths. Nursing diagnoses encourage health care providers to put a label on client's behavior & promotes an "I know best" mentality. Members of the health care community do not confuse medical and nursing diagnoses.
A pregnant client asks the nurse for information on breastfeeding her baby. What type of nursing diagnosis would the nurse formulate? An actual nursing diagnosis A risk nursing diagnosis A possible nursing diagnosis A wellness diagnosis
A wellness diagnosis The client is seeking information related to healthy practices. Wellness diagnoses are formulated to assist the client to meet that need. The client has no health problem or possible problem, so an actual diagnosis, a risk diagnosis, and a possible diagnosis are inappropriate.
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 states that no one should ever ask for help from others. The client has been accompanied by family members to every appointment. The client states a belief in a reward in heaven after death. The client has a long history of health problems. The client has demonstrated effective coping skills in the past.
-The client has been accompanied by family members to every appointment. -The client states a belief in a reward in heaven after death. -The client has demonstrated effective coping skills in the past. The client's support of family members, a belief in an afterlife, and demonstration of effective coping skills in the past are indications that the client will be able to cope with this illness. The client's belief in never asking for help will cause excessive isolation from others. The client's long history of health problems may have exhausted his physical and mental resources.
The nurse recognizes that health problems that can be prevented by independent nursing interventions are called what? Dependent nursing diagnoses Actual or potential nursing diagnoses Collaborative nursing diagnoses Syndrome nursing diagnoses
Actual or potential nursing diagnoses Nursing diagnoses are established based on actual or potential health problems that are identified by the nurse and can be independently addressed. Collaborative diagnoses are selected when the nurse needs to work with another member of the health care team in order to assist the client in resolving the health issue. Dependent nursing diagnoses require a specific written order from the primary health care provider in order to be executed by the nurse. Syndrome nursing diagnoses address a cluster of actual or risk diagnoses that are predicted to be present as a result of a certain event or situation.
A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify? Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor Homelessness Syndrome related to lack of housing as evidenced by visibly soiled clothing Inadequate Hygiene related to homelessness as evidenced by client's stink Impaired Impulse Control related to poor socioeconomic conditions as evidenced by visibly soiled clothing
Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor The most appropriate diagnosis would be "Bathing Self-care Deficit. The client is homeless and would not be able to access bathroom facilities. Homelessness has not been identified as a syndrome and there is only evidence of one problem. Inadequate hygiene has not been identified as a nursing diagnosis; furthermore, the word "stink" is an offensive term which must be avoided in nursing documentation. There is no evidence to suggest that the client has any issues with impulse control.
Which of the following is an example of a nursing diagnosis? Constipation Hypoglycemia Dehydration Depression
Constipation Constipation is a nursing diagnosis included in the Elimination domain. Hypoglycemia, dehydration, and depression are examples of medical diagnoses or medical pathology.
A client reports not having a bowel movement for 7 days, followed by a day of small, loose stools. How does the nurse define the health problem? Constipation related to irregular evacuation patterns Readiness for Enhanced Nutrition related to constipation Bowel incontinence related to depressive state Diarrhea related to client report of small, loose stools
Constipation related to irregular evacuation patterns The client report of constipation followed by loose stools, which indicates a health problem, may exist and establishes the need for professional care. The nurse must decide if the problem is a nursing diagnosis or a collaborative problem, and establish a plan of care accordingly. None of the alternate diagnoses are supported by the data available.
A newly graduated nurse is unable to determine the significance of data obtained during an assessment. What would be the nurse's most appropriate action? The parent states, "I make sure that I get regular exercise." The parent states, "A member of my church gives me a break twice a week." The parent states, "I cannot allow anyone else to help because they won't do it right." The parent states, "I attend support group meetings when I am able to go."
Consult with a more experienced nurse. A newly graduated nurse does not have the experience to interpret all data. The nurse must recognize when a consult with a more experienced nurse is needed. There is no evidence that the nurse needs to collect more data. The data must be documented, but if the data is significant, it may harm the client if no action is taken. There is no need to contact the health care provider at this time.
The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this baby, but I have always believed that abortion is a sin. I don't know what to do." What nursing diagnosis would be most appropriate for the nurse to formulate? Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement Hopelessness related to inability to decide a course of action as evidenced by the client's statement Complicated Grieving related to mental trauma as evidenced by the client's inability to make a decision Ineffective Coping related to rape trauma syndrome as evidenced by client's inability to make a decision
Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement The client's statement indicates that it is difficult for the client to reach a decision because of her moral beliefs. The client is not expressing hopelessness or ineffective coping. The client may be suffering from rape trauma syndrome, but the assessment data does not lead to that diagnosis.
What gives additional meaning to a nursing diagnosis? Composition Descriptors Dysfunction Qualifications
Descriptors Descriptors are words used to give additional meaning to a nursing diagnosis.
A female client undergoing chemotherapy for breast cancer has lost all her hair. The client states, "I cannot stand to see myself without hair. I am disgusting." What would be the most appropriate nursing diagnosis for the nurse to use to address this client's problem? Disturbed Body Image related to breast cancer Disturbed Body Image related to loss of hair Disturbed Body Image as evidenced by client's refusal to look at self Disturbed Body Image as evidenced by client's negative comments
Disturbed Body Image related to loss of hair The client has a problem with her body image because she has lost her hair. The evidence would be the client's statement. The etiology cannot be a medical diagnosis, so the etiology of breast cancer would be incorrect. The other two statements do not contain an etiology. Nursing diagnoses must identify an etiology to direct the client's care.
A client, whose care plan includes a nursing diagnosis of "Risk for infection related to a disruption of skin integrity secondary to abdominal surgery", is displaying redness, edema, and warmth at the surgical site. What would be the nurse's most appropriate revision of the care plan? Formulate the collaborative problem "PC: Infection related to disrupted skin integrity." Revise the nursing diagnosis to include prescribed medication for infection. Formulate the medical diagnosis "Wound infection related to infectious processes." Revise the nursing diagnosis to "Infection as evidenced by redness, edema, and warmth at the surgical site."
Formulate the collaborative problem "PC: Infection related to disrupted skin integrity." When the client is at risk for infection, nurses can care for the client with independent nursing interventions. Once the client becomes infected, antibiotics will be needed which must be prescribed by the physician, which necessitates a collaborative diagnosis. The nursing diagnosis never addresses prescribed medication. Nurses do not formulate medical diagnoses. Actual infection is no longer an independent nursing problem.
Which of the following is classified as a nursing diagnosis? Esophageal cancer Cholecystitis Grieving Pneumonia
Grieving Grieving is a nursing diagnosis per the latest NANDA-I Taxonomy. The other choices are medical diagnoses.
A nurse is caring for a toddler who has been treated on two different occasions for lacerations and contusions due to the parents' negligence in providing a safe environment. What is an appropriate nursing diagnosis for this client? High Risk for Injury related to abusive parents High Risk for Injury related to impaired home management Child Abuse related to unsafe home environment High Risk for Injury related to unsafe home environment
High Risk for Injury related to unsafe home environment The nursing diagnosis "High Risk for Injury related to unsafe home environment" is appropriate because it contains the NANDA-I nursing diagnosis problem statement and the etiology of the problem. High Risk for Injury related to abusive parents is accusatory and may not be accurate. High Risk for Injury related to impaired home management does not accurately identify the etiology of the problem. Child Abuse is not a NANDA-I approved nursing diagnosis.
A client recently diagnosed with pancreatic cancer tells the nurse, "I don't see any hope for my future." What would be the most appropriate nursing diagnosis for the nurse to formulate to address this health problem? Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis Disturbed Self-Concept related to pancreatic cancer diagnosis Ineffective Health Maintenance related to being overwhelmed by cancer diagnosis Knowledge Deficit: Cancer treatment options related to new diagnosis
Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis The client is expressing a lack of hope for the future, which makes "Hopelessness" an appropriate nursing diagnosis. There is no evidence that the client has a disturbed self-concept. There is no evidence that the client is not effectively caring for health. The client does not verbalize a desire to learn about treatment options.
A nurse is interviewing an older adult client who has experienced a drastic weight loss following a CVA (cerebrovascular accident). The client states, "I have trouble getting groceries since I can no longer drive, so I don't have much food in the house." Based on this evidence, what would be the most appropriate nursing diagnosis? Imbalanced nutrition: Less than Body Requirements related to difficulty in procuring food Imbalanced Nutrition: Less than Body Requirements related to drastic weight loss Imbalanced Nutrition: Less than Body Requirements related to cerebrovascular accident Imbalanced nutrition: Less than Body Requirements related to decreased appetite
Imbalanced nutrition: Less than Body Requirements related to difficulty in procuring food The client relates the drastic weight loss to the inability to bring food into the house. The client's statement is the most appropriate etiology for the nursing diagnosis. Drastic weight loss is the evidence of imbalanced nutrition. Cerebrovascular accident is the medical diagnosis. The client could have had a CVA and still have the ability to grocery shop. There is no evidence that the client has lost appetite.
A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain that is interfering with her ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records? Ineffective movement related to arthritis Impaired movements due to pain Impaired physical mobility related to pain Ineffective physical mobility due to pain
Impaired physical mobility related to pain "Impaired physical mobility related to pain" is the correct nursing diagnosis because it consists of an accurate descriptor, diagnostic label, and related factor. "Ineffective movement related to arthritis" is an incorrect entry because the descriptor is incorrect and the diagnostic label is not approved. "Impaired movement due to pain" is an inaccurate entry because the descriptor is inaccurate and the related factor is not written using approved words. "Ineffective physical mobility due to pain" has an erroneous diagnostic label and the related factors are written incorrectly.
A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis? Bronchial Pneumonia Ineffective Airway Clearance Acute Dyspnea Asthma Attack
Ineffective Airway Clearance Since wheezing, shortness of breath, and coughing are signs of a constricted airway, the nursing diagnosis of ineffective airway clearance is the appropriate diagnosis. Bronchial pneumonia and asthma attack are both medical diagnoses. Acute dyspnea is a symptom.
A client with diabetes mellitus has been admitted to the hospital in diabetic ketoacidosis. During the admission assessment of the client, the nurse learns that the client is not following the prescribed therapeutic regimen. The client states, "I don't really have diabetes. My doctor overreacts." What is the most appropriate diagnosis for this client's health problem? Risk for Unstable Blood Glucose related to client's reluctance to manage the diabetic regimen Ineffective Health Maintenance related to client's denial of illness Risk for Injury related to client's mismanagement of disease Ineffective Coping related to client's inability to manage the diabetic regimen
Ineffective Health Maintenance related to client's denial of illness The most appropriate diagnosis is Ineffective Health Maintenance related to client's denial of illness. The data point to the fact that the client is not managing the diabetes, since the client is denying that a problem exists. The client is at risk for unstable blood glucose, but the client's denial is the underlying problem. Risk for Injury relates to safety issues. It is also inappropriate documentation to say the client is "mismanaging" the illness. Ineffective Coping could be an appropriate diagnosis, but the client is not "unable" to manage the illness, just unwilling.
The nurse is admitting a client who is unable to identify person, place, or time. In order to properly analyze this data, what action must the nurse take? Determine the client's medical diagnosis for clarification. Interview the client's family to assess the client's usual level of consciousness. Assess the client's vital signs to determine the client's baseline. Ensure precautions are taken to prevent injury to the client.
Interview the client's family to assess the client's usual level of consciousness. In order to properly analyze the assessment data, the nurse must compare the assessment against the client's normal condition. The family is the best informant for a client with decreased level of consciousness. The medical diagnosis is not necessary to determine if the client's condition is abnormal. Vital signs should be obtained, but the vital signs will not give an indication of the client's usual level of consciousness. Ensuring the client's safety is an important nursing intervention, but will not assist in analyzing the data.
A client has been diagnosed with a recent myocardial infarction. What collaborative problem would be the priority for the nurse to address? PC: Decreased cardiac output related to cardiac tissue damage PC: Disturbed body image related to decreased activity tolerance PC: Activity intolerance related to decreased oxygenation capacity PC: Fear related to new diagnosis of myocardial infarction
PC: Decreased cardiac output related to cardiac tissue damage All these collaborative problems may be indicated for a client with a recent myocardial infarction; however, priority must be given to life threatening issues. Decreased cardiac output is life threatening so it must be the priority concern.
A nurse is planning education about prescription medications for a client newly diagnosed with asthma. What nursing diagnosis would be most appropriate for the nurse to select? Knowledge deficit: Medications related to new medical diagnosis Ineffective Airway Clearance related to bronchial constriction Noncompliance related to deficient knowledge of a new medical diagnosis Anticipatory Grieving related to chronic illness management
Knowledge deficit: Medications related to new medical diagnosis To most appropriately address the client's health problem, the nurse should educate the client about the new medications the physician has prescribed to treat the asthma. Ineffective airway clearance refers to the physiologic processes of asthma. There is no evidence of noncompliance. There is no indication that the client is having difficulty dealing with the diagnosis.
The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action? Notify the physician for additional orders. Document the client's level of consciousness. Consult with another nurse to validate the assessment. Decrease stimulation and allow the client to rest.
Notify the physician for additional orders. The client's decreased level of consciousness could indicate that the client is developing an electrolyte imbalance. The change in the client's status requires notification of the physician. Medication orders are required to treat the electrolyte imbalance. Documenting the level of consciousness is appropriate, but not as the priority action. Another nurse is not necessary to check the nurse's assessment. Decreasing stimulation and allowing the client to rest with no further action may result in harm to the client.
A nurse documents the following in the client chart: Risk for Decreased Cardiac Output related to myocardial ischemia. This is an example of what aspect of client care? Nursing diagnosis Nursing assessment Medical diagnosis Collaborative problem
Nursing diagnosis The nursing diagnosis statement is worded by stating the client problem (using NANDA-I approved diagnoses) that the nurse is able to treat followed by the etiology of the problem. Nursing assessment refers to the collection of data. A medical diagnosis identifies diseases, whereas nursing diagnoses focus on unhealthy responses to health and illness. Nurses cannot treat medical diagnoses independently. Collaborative problems are the primary responsibility of nurses. Unlike nursing diagnoses, with collaborative problems, the prescription for treatment comes from nursing, medicine, and other disciplines.
A client admitted for a surgical procedure tells the nurse, "I am very worried because I am allergic to latex. I want to make sure that everyone knows this." In order to assure the safety of the client, what nursing diagnosis would the nurse address? Anxiety related to surgical procedure Knowledge Deficit related to surgical procedure Risk for Allergy Response related to latex allergy Risk for Injury related to latex allergy
Risk for Allergy Response related to latex allergy To assure the safety of the client, the nurse must address the risk for an allergic response due to the client's latex allergy. Anxiety refers to a vague feeling of dread; however, the client is responding with fear to a very real threat. There is no evidence that the client does not understand the surgical procedure. Risk for Injury is not an appropriate diagnosis, because it does not adequately address the specific health problem.
A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern? Knowledge Deficit related to effects of chemical plant pollution Deficient Community Health related to chemical plant Risk for Community Contamination related to possible environmental pollution Risk for Infection related to community contamination
Risk for Community Contamination related to possible environmental pollution The nurse has identified a risk diagnosis because of the unknown health effects of the chemical plant on the community. Risk for community contamination would address the broad concerns of the nurse. Knowledge deficit is not appropriate because it has too narrow a focus. Deficient community health is not a NANDA-I diagnosis and the etiology must deal with how the plant may possibly affect the community. Risk for infection has a very narrow focus. The etiology of community contamination has not been proven.
Which is an accurately phrased risk diagnosis? Risk for Impaired Coping as evidenced by client crying. Risk for Fluid Volume Excess related to increased oral intake as evidenced by consuming 3 L of soda. Risk for Pain After Surgery. Risk for Falls related to altered mobility.
Risk for Falls related to altered mobility. Risk for Falls related to altered mobility is an accurately phrased risk diagnosis. It is a two-part statement that contains the diagnostic statement (altered mobility) and risk factors (risk for falls).
Which statement appropriately identifies an at-risk nursing diagnosis for a woman 78 years of age who is confined to bed? Ineffective airway clearance related to bed rest Immobility related to confinement to bed Potential for pneumonia related to inactivity Risk for impaired skin integrity related to bed rest
Risk for impaired skin integrity related to bed rest An at-risk nursing diagnosis, as defined by NANDA-I, "describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community."
A client diagnosed with advanced lung cancer has a nursing diagnosis of Ineffective Coping. What assessment data would provide evidence to the nurse for this diagnosis? The client asks about hospice services. The client makes funeral plans. The client states, "I am sure the doctors have misdiagnosed me." The client states, "I hope that I am able to attend my daughter's wedding."
The client states, "I am sure the doctors have misdiagnosed me." Denying the illness by stating a belief that the cancer diagnosis is incorrect is evidence that the client is not dealing with the illness. Inquiring about hospice and making funeral plans shows acceptance of the advanced stage of the illness. Stating a hope to attend the daughter's wedding is expressing hope for the future and is evidence of effective coping.
The nurse has identified a nursing diagnosis of "Risk for Impaired Parenting" for a client who has recently learned of her pregnancy. What assessment data would be appropriate to lead the nurse to select this diagnosis? The client states, "I am shocked to find out that I am pregnant." The client states, "I do not plan to tell my family about my pregnancy right away." The client states, "I do not know how to take care of a baby." The client states, "I know that I will have to make some changes in my life."
The client states, "I do not know how to take care of a baby." It is not unusual to feel unprepared to care for baby. However, this warrants the nurse's attention because there is an associated risk of impaired parenting. Being shocked about the pregnancy and making changes in her life are all normal reactions to finding out about a pregnancy and do not necessarily indicate future problems. The nurse must work with the client about her communication with her family, but this does not necessarily mean that her parenting will be compromised.
The nurse is caring for a client who has been diagnosed with a sexually transmitted infection (STI). The nurse plans to address the nursing diagnosis of Risk Prone Behavior. What assumption has the nurse made? The nurse has assumed that having a sexually transmitted infection means the client is sexually promiscuous. The nurse has assumed that the client needs education to decrease the likelihood of repeated infection. The nurse has assumed that having a sexually transmitted infection means the client is unaware of the risks of unprotected sex. The nurse has assumed that the client does not understand the complications of sexually transmitted infections.
The nurse has assumed that having a sexually transmitted infection means the client is sexually promiscuous. Risk Prone Behavior identifies habits of the client that are dangerous. Being sexually promiscuous would be a dangerous behavior. Risk prone behavior does not mean that the client is not knowledgeable or needs further instructions about complications.
During a home health care visit, the nurse identifies a nursing diagnosis of Caregiver Role Strain for a parent who is caring for a child dependent on a ventilator. What subjective assessment data would support the nurse's diagnosis?
The parent states, "I cannot allow anyone else to help because they won't do it right."
A nurse who believes strongly that women should make their own decisions is caring for a female client from a culture where women defer decisions to their husbands. Based on the client's insistence that her husband make all decisions for her, the nurse formulates a nursing diagnosis of "Dysfunctional Family Processes." What type of nursing diagnosis error has the nurse made? The nurse has not selected the correct nursing diagnosis to address this problem. The nurse has inserted her own beliefs into the interpretation of the data. The nurse is not addressing the reason the client is seeking health care. The nurse needs further evidence to validate this diagnosis.
The nurse has inserted her own beliefs into the interpretation of the data. The nurse has made an error by using her own beliefs that women should make autonomous decisions. She is taking a paternalistic attitude toward the client's cultural beliefs. There is no health care problem, so no nursing diagnosis is necessary. The nurse is not addressing the reason the client is seeking health care, but that is not an issue at this time. The nurse would need further evidence to make this nursing diagnosis; however, there is no evidence to make the diagnosis at all.
When reviewing the client's history, the nurse notes that it has been recorded that the client's last bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "Constipation," what assessment must the nurse make? The nurse should assess the client's dietary habits. The nurse should assess the client's bowel sounds. The nurse should determine the client's normal bowel elimination pattern. The nurse should determine the standard bowel elimination pattern for the client's age.
The nurse should determine the client's normal bowel elimination pattern. In order to validate the diagnosis, the nurse must determine what is the normal for the client. Dietary habits may contribute to the constipation, but do not evidence the nursing diagnosis. Assessing bowel sounds would be important data, but would not evidence the diagnosis of constipation. There is no standard elimination pattern; it is highly individualized.
During morning report, the night nurse tells the day nurse that the client refused to allow the technician to draw blood for laboratory testing. What step would be essential for the day nurse to complete before selecting a nursing diagnosis to address this issue? The nurse should determine the length of time the client has been in the hospital. The nurse should determine what laboratory tests are critical at this time. The nurse should determine the reason for the client's refusal. The nurse should determine the client's last laboratory results.
The nurse should determine the reason for the client's refusal. Before addressing the issue, the nurse must determine why the client refused the lab draw. It is essential to know the cause before planning how to address the issue. It is immaterial how long the client has been in the hospital, what laboratory tests are critical, or what the client's last results were.
A client who gave birth yesterday refuses to eat the food provided by the hospital. She states that she must eat special food brought from home by her family. How would the nurse most appropriately address this situation? The nurse should plan no action because the client is not exhibiting a health problem. The nurse should formulate a possible nursing diagnosis and make further observations. The nurse should formulate an active nursing diagnosis and plan interventions to correct the problem. The nurse should formulate a collaborative problem and consult with the physician and dietitian.
The nurse should plan no action because the client is not exhibiting a health problem. Many cultures require the new mother to eat specially prepared food. The client is simply following her own cultural practices. No problem exists and no plan is indicated to address it.
The nurse is aware that development of nursing diagnoses are: both within the nursing scope of practice and are client focused. collaborative in nature and dependent on the medical diagnosis. based on assessment data and the primary care provider's input. dictated by the medical diagnoses and change day by day.
both within the nursing scope of practice and are client focused. Nursing diagnoses may change from day to day as the client's responses change. Collaboration is used in the management of nursing care. However, selecting a nursing diagnosis is a function of nursing.
A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues provide organization, or: categorizing. diagnosing. grouping. clustering.
clustering Cue clustering brings together cues that if viewed separately would not convey the same meaning.
Which example of client care is not the responsibility of the nurse? monitoring for changes in health status promoting safety and preventing harm; detecting and controlling risks tailoring treatment and medication regimens for each individual confirming a medical diagnosis
confirming a medical diagnosis The nursing scope of practice dictates what is allowed and not allowed when providing nursing care. Confirming a medical diagnosis is not in the scope of nursing practice. Monitoring for changes in a client's health status, promoting safety and preventing harm, and tailoring treatment and medication regimens to the client's schedule of activities are all nursing care responsibilities.
What is the nurse accountable for, according to state nurse practice acts? managing the care team effectively making nursing diagnoses prescribing PRN (as needed) medications mentoring other nurses
making nursing diagnoses State nurse practice acts have included diagnosis as part of the domain of nursing practice for which nurses are held accountable. Overall management of the care team is not an explicit responsibility of nurses. Nurses generally do not have prescriptive authority. The responsibility for mentorship is not enacted in law.
A nurse makes a nursing diagnosis of Constipation after a client tells her he did not defecate on his last trip to the bathroom. The nurse has no other information on the client's defecation history. This is an example of: inconsistent cues. premature closure. clustering of cues. cluster interpretation.
premature closure. Premature closure is when the nurse selects a nursing diagnosis before analyzing all of the pertinent information in the client's case. The nurse did not investigate any other information in this case before making her diagnosis. Inconsistent cues occur when the meaning attached to one cue may be altered based on another cue. The client did not provide any additional cues for this to be the correct answer. Clustering of cues is a clustering of data.
When caring for a client, the nurse identifies and analyzes data to identify nursing diagnoses and collaborative problems. Which action is a priority role of the nurse when caring for a client with collaborative problems? identifying the client's understanding of risk factors resolving health issues through independent nursing measures reporting trends that suggest development of complications managing an emerging problem with the help of another registered nurse
reporting trends that suggest development of complications The nurse should report trends that suggest development of complications to bring to notice the need for collaborative intervention for a client. Collaborative problems are physiologic complications that require both nurse- and physician-prescribed interventions. Actions that exclude members of other disciplines are not characteristic of collaborative problem management. The development of complications is a priority over assessment of the client's knowledge of risk factors, even though these must be assessed.
What is the purpose of establishing a nursing diagnosis? to describe a functional health problem to collaborate with the physician to identify medical problems to meet accreditation criteria
to describe a functional health problem Establishment of a nursing diagnosis reflects the synthesis of data gathered during a nursing assessment. Gordon suggested a framework for organizing nursing diagnoses based on functional health, thus offering a convenient way to cluster similar diagnoses.