chapter 17 nursing diagnosis

Which question would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea? "What types of foods do you think caused your upset stomach?" "How many bowel movements a day have you had?" "Are you able to get to the bathroom in time?" "What medications are you currently taking?"

"How many bowel movements a day have you had?"

Which of the following is a diagnostic error involving identification of a goal of care rather than a patient need? 1. Patient obtains social support care related to caregiver stress 2. Fear related to open-heart surgery 3. Acute Pain related to splinting of incision 4. Impaired Family Coping related to insufficient caregiver support

1

A nurse is developing nursing diagnoses for a patient. Beginning with the first step, place in order the steps the nurse will use.1. Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma.2. Writes a diagnostic label of impaired gas exchange.3. Organizes data into meaningful clusters.4. Interprets information from patient.5. Writes an etiology.

1, 3, 4, 2, 5

Which of the following best describe a collaborative health problem? (Select all that apply.) 1. An actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's health status 2. The language medical practitioners use to communicate a patient's health problem and associated treatments and response 3. A diagnostic label that classifies a patient's response to illness so that all nurses can be familiar with a specific patient's health care needs 4. A language used by health care providers to communicate and consider each other's unique perspective, so they can better manage the multiple factors that influence the health of individuals 5. A diagnosis that provides clear direction as to the type of nursing interventions nurses are licensed to provide independently

1, 4

A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment, has liquid stool, and the skin is clean and intact. The student selects the nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student has made a diagnostic error for which of the following reasons? 1. Incorrect clustering of data 2. Wrong diagnosis 3. Condition is a collaborative problem 4. Premature ending assessment

2

A nurse reviews data gathered regarding a patient's response to a diagnosis of cancer. The nurse notes that the patient is restless, avoids eye contact, has increased blood pressure, and expresses a sense of helplessness. The nurse compares the pattern of assessment findings for Anxiety with those of Fear and selects Anxiety as the correct diagnosis. This is an example of the nurse avoiding an error in? (Select all that apply.) 1. Data collection 2. Data clustering 3. Data interpretation 4. Making a diagnostic statement 5. Goal setting

2, 3, 4

A nurse is assigned to a new patient admitted to the medical unit. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order. 1. Consider the context of patient's health problem and select a related factor. 2. Review assessment data, noting objective and subjective clinical information. 3. Cluster clinical data elements that form a pattern. 4. Identify appropriate assessment findings for diagnosis. 5. Identify a nursing diagnosis.

2, 3, 5, 1, 4

A nurse conducts an assessment of a 42-year-old woman at a health clinic. The woman is married and lives in a condo with her husband. She reports having frequent voiding and pain when she passes urine. The nurse asks whether she has to go to the bathroom at night, and the patient responds, "Yes, usually twice or more." The patient had an episode of diarrhea 1 week ago. She weighs 300 lb and reports having difficulty cleansing herself after voiding or passing stool. Which of the following demonstrate assessment findings that cluster to indicate the nursing diagnosis Impaired Urination. (Select all that apply.) 1. Age 42 2. Dysuria 3. Difficulty performing perineal hygiene 4. Nocturia 5. Episode of diarrhea

2, 4

Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.) 1. Offer frequent skin care because of Impaired Skin Integrity 2. Risk of Infection 3. Chronic Pain related to osteoarthritis 4. Activity Intolerance related to physical deconditioning 5. Lack of Knowledge related to laser surgery

2, 4

A nurse interviews and conducts a physical examination of a patient that includes the following findings: reduced movement of lower leg, reduced range of motion in left knee, and difficulty turning in bed without assistance. This data set is an example of: 1. Collaborative data set. 2. Diagnostic label. 3. Related factors. 4. Data cluster.

4

For a student to avoid a data collection error, the student should: A. assess the patient and, if unsure of the finding, ask a faculty member to assess the patient. B. review his or her own comfort level and competency with assessment skills. C. ask another student to perform the assessment. D. consider whether the diagnosis should be actual, potential, or risk.

A

A nurse adds the following diagnosis to a patient's care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic? Decreased gastrointestinal motility Pain medication Abdominal distention Constipation

Abdominal distention

A patient presents to the emergency department following a motor vehicle crash that causes a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care? Posttrauma syndrome Constipation Acute pain Anxiety

Acute Pain

A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse document? Decreased cardiac output related to altered myocardial contractility. Patient needs a low-fat diet related to inadequate heart perfusion. Offer a low-fat diet because of heart problems. Acute heart pain related to discomfort.

Decreased cardiac output related to altered myocardial contractility.

The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, reports of shortness of breath when getting out of bed, and a productive cough. Which elements will the nurse identify as defining characteristics for the diagnostic label of Activity intolerance? Decreased oral intake and decreased oxygen saturation when ambulating Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed Reports of shortness of breath when getting out of bed and a productive cough Productive cough and decreased oral intake

Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed

Concept mapping is one way to: A. connect concepts to a central subject. B. relate ideas to patient health problems. C. challenge a nurse's thinking about patient needs and problems. D. graphically display ideas by organizing data. E. all of the above.

E

The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part of the diagnostic statement does the nurse need to revise? Etiology Nursing diagnosis Collaborative problem Defining characteristic

Etiology

A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write? Risk Problem focused Health promotion Collaborative problem

Health promotion

A new nurse writes the following nursing diagnoses on a patient's care plan. Which nursing diagnosis will cause the nurse manager to intervene? Wandering Hemorrhage Urinary retention Impaired swallowing

Hemorrhage

A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write? Ineffective breathing pattern related to pneumonia Risk for infection related to chest x-ray procedure Risk for deficient fluid volume related to dehydration Impaired gas exchange related to alveolar-capillary membrane changes

Impaired gas exchange related to alveolar-capillary membrane changes

A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to the patient's care plan? Infection Risk for infection Impaired skin integrity Staphylococcal leg infection

Impaired skin integrity

A nurse is developing nursing diagnoses for a group of patients. Which nursing diagnoses will the nurse use? (Select all that apply.) Anxiety related to barium enema Impaired gas exchange related to asthma Impaired physical mobility related to incisional pain Nausea related to adverse effect of cancer medication Risk for falls related to nursing assistive personnel leaving bedrail down

Nausea related to adverse effect of cancer medication Impaired physical mobility related to incisional pain

After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse's actions? To form a language that can be encoded only by nurses To distinguish the nurse's role from the physician's role To develop clinical judgment based on other's intuition To help nurses focus on the scope of medical practice

To distinguish the nurse's role from the physician's role

Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved? Sore throat Acute pain Sleep apnea Heart failure

acute pain

Concept mapping is one way to: connect concepts to a central subject. relate ideas to patient health problems. challenge a nurse's thinking about patient needs and problems. graphically display ideas by organizing data. all of the above.

all of the above

For a student to avoid a data collection error, the student should: assess the patient and, if unsure of the finding, ask a faculty member to assess the patient. review his or her own comfort level and competency with assessment skills. ask another student to perform the assessment. consider whether the diagnosis should be actual, potential, or risk.

assess the patient and, if unsure of the finding, ask a faculty member to assess the patient.

A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. The nurse analyzes the data. Which nursing diagnosis will the nurse assign to the patient? Adult failure to thrive Adult failure to thrive Deficient fluid volume Nausea

deficient fluid volume

The nurse is reviewing a patient's database for significant changes and discovers that the patient has not voided in over 8 hours. The patient's kidney function lab results are abnormal, and the patient's oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review? Diagnosis Planning Implementation Evaluation

diagnosis