Chapter 12 Diagnosing

The nurse is using the Taxonomy II nursing diagnoses system. What axes should the nurse realize are coded within this system? Standard Text: Select all that apply. 1. Gordon's health pattern groupings 2. Age 3. Time 4. Health status 5. Gender 6. Location

2. Age 3. Time 4. Health status 6. Location

The nurse has completed the initial assessment of a client and has analyzed and clustered the data. What should the nurse complete next in the diagnostic process? 1. Formulate a diagnosis. 2. Verify the data. 3. Research collaborative and nursing-related interventions. 4. Identify the client's problem, health risks, and strengths.

4. Identify the client's problem, health risks, and strengths. Rationale 4: The step that follows data analysis is identification of the client's health problems, health risks, and strengths.

A client is diagnosed with pneumonia and has been hospitalized for several days. Which nursing diagnosis should the nurse identify as a priority for this client? 1. Altered oral mucous membranes, related to dry mouth 2. Activity intolerance, related to oxygen supply imbalance 3. Knowledge deficit, related to medication regimen 4. Ineffective airway clearance, related to increased secretions

4. Ineffective airway clearance, related to increased secretions Rationale 4: Prioritizing care must begin with the basic needs, in this case, the airway.

The nurse is preparing to write nursing diagnoses for a client. What should the nurse recall about the NANDA label? 1. Must contain three components 2. Describes the health problem for which nursing therapy is given 3. Helps define medical diagnoses for nursing 4. Promotes a taxonomy of nursing

4. Promotes a taxonomy of nursing Rationale 4: The purpose of the NANDA label is to define, refine, and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses. This label describes the health problem or response by the client for which nursing therapy is given.

The nurse is providing care to a client. Which nursing diagnoses can the nurse apply when providing client care? Standard Text: Select all that apply. 1. Ineffective Breathing Pattern 2. Risk of Infection 3. Readiness for Enhanced Nutrition 4. Readiness for Enhanced Family Coping 5. Anxiety

1. Ineffective Breathing Pattern 5. Anxiety

The nurse is using the PES model to write a nursing diagnosis. Which nursing diagnoses demonstrate that the nurse used this model appropriately? Standard Text: Select all that apply. 1. Ineffective coping related to depression as evidenced by suicide attempt 2. Noncompliance (DASH diet) related to denial of having disease 3. Risk for infection related to recent surgery 4. Nutrition less than adequate related to anxiety as evidenced by weight loss of ten pounds 5. Ineffective Breathing Pattern as evidenced by cyanotic lips

1. Ineffective coping related to depression as evidenced by suicide attempt. 4. Nutrition less than adequate related to anxiety as evidenced by weight loss of ten pounds

The nurse is preparing to formulate nursing diagnoses for a client desiring information to help with chronic low back pain. Which human response patterns should the nurse keep in mind when formulating the diagnoses for this client? Standard Text: Select all that apply. 1. Moving 2. Choosing 3. Perceiving 4. Anticipating 5. Communicating

1. Moving 2. Choosing 3. Perceiving 5. Communicating

The nurse is reviewing assessment data collected for a client's care plan. What criteria should the nurse use when formulating this client's nursing diagnoses? Standard Text: Select all that apply. 1. Nonjudgmental statements 2. Stated in terms of a need 3. Must be legally advisable 4. Cause/effect correctly stated 5. Medical terminology used to describe the cause 6. Diagnosis worded specifically and precisely

1. Nonjudgmental statements 3. Must be legally advisable 4. Cause/effect correctly stated 6. Diagnosis worded specifically and precisely

The nurse has formulated a diagnosis of Activity intolerance related to decreased airway capacity for a client with chronic asthma. In looking at the client's coping skills, the nurse realizes that the client has a vast knowledge about the disease and what exacerbates symptoms in particular situations. Why should the nurse utilize this information? 1. Strengths can be an aid to mobilizing health and the healing process. 2. The client will be more active in the plan. 3. It will be easier for the nurse to educate the client about other interventions. 4. The nurse won't have to spend time going over the pathology of the client's disease.

1. Strengths can be an aid to mobilizing health and the healing process. Rationale 1: Establishing strengths, resources, and ability to cope will help the client develop a more well-rounded self-concept and self-image. Strengths can be an aid to mobilizing health and regenerative processes.

A client who has been in a wheelchair for several years is currently experiencing problems with skin breakdown and urinary retention in addition to depression. Which diagnosis should the nurse select for this client? 1. Syndrome diagnosis 2. Risk nursing diagnosis 3. Actual diagnosis 4. Wellness diagnosis

1. Syndrome diagnosis Rationale 1: A syndrome diagnosis is a diagnosis that is associated with a cluster of other diagnoses (in this situation, Urinary elimination alteration, Impaired skin integrity, and Powerlessness).

The nurse has formulated a nursing diagnosis of Impaired skin integrity related to poor hygienic practice, secondary to current living conditions for a client. Which data did the nurse use to support this diagnosis? Standard Text: Select all that apply. 1. The client has dry, cracked skin. 2. The client has one large and several smaller open, ulcerated areas on his right leg. 3. The client does not drive. 4. The client states that he does not use alcohol or drugs. 5. The client's clothes are soiled. 6. The client has obvious body odor.

1. The client has dry, cracked skin. 2. The client has one large and several smaller open, ulcerated areas on his right leg. 5. The client's clothes are soiled. 6. The client has obvious body odor.

The nurse selects the nursing diagnosis of Enhanced readiness for spiritual well-being for a family. Which data cluster did the nurse use to support this diagnosis? 1. The family visits different congregations, the parents have been reflecting on their own spiritual upbringings, and the children are questioning rituals of their friends and friends' families. 2. The children attend Sunday school classes, one parent always attends services with the children, and the parents attempt interaction with congregational activities. 3. The grandparents go to weekly services and have formal interaction with clergy. 4. The children have attended private, religious schools, and the parents are involved in the school's activities.

1. The family visits different congregations, the parents have been reflecting on their own spiritual upbringings, and the children are questioning rituals of their friends and friends' families. Rationale 1: A wellness diagnosis describes human responses to levels of wellness in an individual family or community that has a readiness for enhancement or improvement. The data cluster that describes the questioning, searching, and reflecting would support an attitude of readiness.

After an assessment, the nurse reviews the list of client problems. For which problems should the nurse create nursing diagnoses? 1. The ones that the nurse is licensed to treat 2. The ones that address other health professionals' interventions 3. The ones that focus on the client's primary illness 4. The ones that have standardized care available

1. The ones that the nurse is licensed to treat Rationale 1: The domain of nursing diagnoses includes only those health states that nurses are educated on and licensed to treat. A nursing diagnosis is a judgment made only after data collection. Nursing diagnoses describe a continuum of health states: deviations from health, presence of risk factors, and areas of enhanced personal growth.

A client who has just been diagnosed with pancreatic cancer is quite upset and verbal. The nurse has formulated the following diagnosis: Anxiety, related to unfamiliarity of disease process, manifested by restlessness and tachycardia. What is the etiology of this diagnosis? 1. Unfamiliarity of disease process 2. Anxiety 3. Restlessness 4. Tachycardia

1. Unfamiliarity of disease process Rationale 1: The etiology is the underlying cause and a contributing factor of the client's response. In this case, the uncertainty of the diagnosis, fear of the unknown, and response to the diagnosis cause the client to become anxious and upset.

The nurse formulates nursing diagnoses for a client with chronic renal failure. Which statements indicate the nurse appropriately used a two-part format? Standard Text: Select all that apply. 1. Pruritis related to toxin build-up in the blood 2. Hypertension related to fluid volume overload 3. Deficient fluid volume related to fluid restriction 4. Personal care challenges related to fistula in left arm 5. Acute confusion related to delayed hemodialysis treatment

3. Deficient fluid volume related to fluid restriction 5. Acute confusion related to delayed hemodialysis treatment

The nurse formulates the nursing diagnosis: Acute pain, related to tissue damage, secondary to infarction, manifested by pallor, client report, and shallow, rapid breathing for a client experiencing an acute myocardial infarction. Which collaborative action would be appropriate for this client? 1. Provide a calm, quiet atmosphere in the client's room. 2. Administer pain medication. 3. Educate the client and family regarding treatment and therapies. 4. Monitor for changes in the client's condition.

2. Administer pain medication. Rationale 2: Collaboration occurs between the nurse, physician, and other health care professionals to treat the client's problem. In this case, the physician prescribes medications, and the nurse administers them—a primarily dependent action that requires physician orders.

A client has been having pain without any clear pathology for cause. Which nursing diagnosis should the nurse identify as being the most appropriate for this client? 1. Pain due to unknown factors 2. Pain related to unknown etiology 3. Pain caused by psychosomatic condition 4. Pain manifested by client's report

2. Pain related to unknown etiology Rationale 2: The second part of the nursing diagnosis statement is the etiology (E)—the factors contributing to or probable causes—and should be joined to the first part, the problem (P), by the words "related to" rather than "due to." The phrase "related to" implies a relationship between the problem and the cause. In this situation, the cause is unknown, but the problem is evident.

An experienced nurse has just walked into the room of a newly assigned client. Which observation should the nurse use to include a new nursing diagnosis in this client's plan of care? 1. The client's eyes are closed. 2. The client's skin is pale and mottled. 3. The client's spouse is asleep in the chair next to the bed. 4. The television is on and the volume is turned up.

2. The client's skin is pale and mottled. Rationale 2: Nurses draw on knowledge and experience to compare client data to standards and norms and to identify significant and relevant observations. An observation is considered significant if it points to changes in the client's health status or pattern, varies from norms of the client population, or indicates a developmental delay. Pale, mottled skin could indicate coldness, a problem with circulation, or even death.

After communicating with the client and family, the nurse compares a client's problem list with identified nursing diagnoses. What action is the nurse performing to minimize diagnostic errors? 1. Understanding what is normal vs. what is not normal 2. Verifying 3. Consulting resources 4. Basing diagnoses on patterns

2. Verifying Rationale 2: The nurse, while taking the information and collecting data, begins to hypothesize possible explanations of the data and then realizes all diagnoses are only tentative until they are verified. The client and family should be included in the beginning and also at the end of the diagnostic process to verify the nurse's diagnoses.

After formulating several diagnoses, the nurse does not understand the reason for some of the discrepancies in the client's lab values and diagnostic tests, when comparing to norms and standards. Which action should the nurse take? 1. Verify the information with the client. 2. Compare all findings to the national norms and standards. 3. Consult other professionals and colleagues. 4. Improve critical thinking skills so answers come more easily.

3. Consult other professionals and colleagues. Rationale 3: Both novices and experienced nurses should consult appropriate resources whenever in doubt about a diagnosis. Professional literature, nursing colleagues, and other professionals are all appropriate resources.

The nurse is caring for a client recovering from a long and difficult childbirth experience. Which nursing diagnosis did the nurse write appropriately for this client? 1. Constipation, due to tissue trauma, manifested by no bowel movement for 2 days 2. Risk for infection, because of new incision, related to episiotomy 3. Ineffective breast-feeding, related to lack of motivation, secondary to exhaustion 4. Altered urinary elimination, secondary to childbirth

3. Ineffective breast-feeding, related to lack of motivation, secondary to exhaustion Rationale 3: The problem statement is listed first (NANDA label), followed by the etiology—factors that contribute to or are the cause of the client's response. The two parts are joined by the words "related to," implying a relationship between the two. Adding a second part to the etiology statement makes it more descriptive and useful.

The nurse is reviewing information about the formulation of nursing diagnoses. What should the nurse identify as the area in which nursing diagnoses differ from medical diagnoses and collaborative problems? 1. Mental status of the client 2. Chronic nature of the illness 3. Nursing care focus 4. Prognosis

3. Nursing care focus Rationale 3: Nursing focus is an area that differs.

The nurse has formulated the following diagnosis: Activity intolerance, related to weakness and debilitation, manifested by reports of fatigue after any physical activity. What is the defining characteristic of this label? 1. Activity intolerance 2. Weakness and debilitation 3. Reports of fatigue 4. Physical activity

3. Reports of fatigue Rationale 3: The defining characteristics are those reports given by the client, or the signs and symptoms.

The nurse wants to propose a new nursing diagnosis. What action should the nurse take first? 1. Using the proposed nursing diagnosis when constructing client care plans 2. Getting permission for the proposed nursing diagnosis to be implemented by a nursing facility 3. Submitting the diagnosis to NANDA's Diagnostic Review Committee 4. Presenting the proposed nursing diagnosis at the local AMA (American Medical Association) meeting.

3. Submitting the diagnosis to NANDA's Diagnostic Review Committee Rationale 3: This is the recognized procedure for initiating the approval of a new nursing diagnosis.

The graduate nurse is struggling with identifying cues from clustered data. What should the nurse use to recognize data patterns and cues? 1. Depend on knowledge gained from peers' experiences. 2. Work with seasoned and experienced nurses and learn from them. 3. Take assessment notes and utilize information from textbooks for comparison. 4. Know that this will take time, and experience is the best teacher.

3. Take assessment notes and utilize information from textbooks for comparison. Rationale 3: The novice nurse must take careful assessment notes, search data for abnormal cues, and use textbook resources for comparing the client's cues with the defining characteristics and etiologic factors of the accepted nursing diagnoses.

A client comes to the clinic seeking information and education regarding healthy lifestyles and eating habits. Which type of diagnosis should the nurse select for this client? 1. Risk nursing diagnosis 2. Syndrome diagnosis 3. Wellness diagnosis 4. Actual diagnosis

3. Wellness diagnosis Rationale 3: A wellness diagnosis describes the human response to levels of wellness in an individual. This client is seeking information about behavior changes and improvement to assist him in making choices and changes to enhance his life.

The nurse is formulating a nursing diagnosis for a client with a long, extensive history of psychiatric problems, beginning in childhood, who is being placed in a long-term, structured institutional environment. Which diagnosis indicates the client's problem is adequately described? 1. Chronic low self-esteem, related to factors too numerous to mention 2. Risk for self-harm, related to many psychiatric problems 3. Impaired social interaction, due to long history of institutionalization 4. Alteration in thought processes, related to complex factors

4. Alteration in thought processes, related to complex factors Rationale 4: The phrase "complex factors" may be used when there are too many etiologic factors or when they are too complex to state in a brief phrase. The actual cause of this client's altered thought process may be due to psychiatric diagnoses, medication tolerances and noncompliance, history of institutionalization, and life history of mental disease. This is a variation of the basic two-part statement, but is acceptable to use.