Course Point - Chapter 12: Diagnosing

Medical diagnoses

identify diseases

A nurse is preparing to write a nursing diagnosis for a client. Which activity would the nurse need to do first?

identify the significant data The first step is to look at the data for cues. Significant data or cues will then be clustered. During cue clustering, critical thinking is used to analyze and synthesize the cues; that is, how they fit into a particular problem. The cues are then put together to form meaningful clusters that describe specific client problems. Cluster interpretation involves synthesizing the cue clusters; that is, to see the whole picture and attach meaning to the cluster. Once the nursing diagnosis is selected, it should be validated with the client.

Standard

norm, generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category.

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." 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 male client age 67 years has right lower quadrant pain that has been diagnosed as appendicitis and subsequently treated by open appendectomy. How should the nurse document a potential complication related to this client's diagnosis and treatment?

"PC: Atelectasis related to surgery" To write a diagnostic statement for a collaborative problem, focus on the potential complications of the problem. Use "PC" (for potential complication), followed by a colon, and list the complications that might occur. For clarity, link the potential complications and the collaborative problem by using "related to." (less)

Purposes of Diagnosing

1. Identify how a person, group, or community responds to actual or potential health and life processes 2. Identify factors that contribute to or cause health problems (etiologies). 3. Identify resources or strengths that the person, group, or community can draw on to prevent or resolve problems.

The nurse caring for a client with obesity would like to address the possible health problems that can develop related to obesity. To plan care for this client, what type of nursing diagnosis would the nurse formulate?

A risk nursing diagnosis Since the nurse is trying to address health problems that the client is at risk for because of obesity, the appropriate diagnosis is a risk nursing diagnosis. The nurse is not addressing a health problem that the client has or a health problem that the nurse needs more information to validate, so an actual or possible nursing diagnosis is not appropriate. The client is not seeking health information, so a wellness diagnosis in inappropriate.

A pregnant client asks the nurse for information on breastfeeding her baby. What type of nursing diagnosis would the nurse formulate?

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. (less)

A nurse is treating a client with congestive heart failure. The client informs the nurse that he is having difficulty walking up the stairs in his home. He is frustrated because he used to be a runner, and now he can barely walk to the store. Which is an accurate actual nursing diagnosis for this client?

Activity Intolerance related to congestive heart failure as evidenced by inability to walk up and down stairs. When considering the responses, first check for sentence structure. Only one of the choices contains the three elements of the nursing diagnosis: the diagnostic label, the related factors, and the defining characteristics. The question asks for an actual diagnosis; this eliminates any risk, wellness, or potential diagnoses.

"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 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.

Nursing diagnoses

Actual or potential health problems that can be prevented or resolved by independent nursing intervention.

The nurse recognizes that health problems that can be prevented by independent nursing interventions are called what?

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 19-year-old male college basketball player is being evaluated for injuries after a skiing accident. The nurse determines the client has a pulse of 52. What would be the most appropriate way for the nurse to determine the significance of the client's heart rate?

Ask the client if the heart rate is normal to him. A well-conditioned male athlete will very likely have a pulse lower than normal at rest. The key assessment is to compare the current heart rate with the client's baseline. Asking the client would be a simple way of confirming it. Comparing the client's heart rate to another teenage client does not take into account the individual differences of clients. If a nurse is competent in physical assessment, there is no need to have another nurse check the heart rate. The pulse rate of 52 does not indicate any risk for cardiac disease. The client is also being seen in the emergency room for an urgent health problem. This assessment can wait until later.

A nurse has selected a nursing diagnosis and is preparing to validate it. With whom would the nurse do this?

Client After selecting a nursing diagnosis (Ineffective Role Performance, in the clinical example), the nurse should validate it with the client. Validation legitimizes the diagnosis and helps to discover its significance for the client.

While developing a plan of care for a client, what should the nurse do before selecting a nursing diagnosis?

Collect client subjective and objective data. Nursing diagnoses are developed as the second step of the nursing process. The first step is to collect all assessment data so that appropriate actual or potential nursing problems can be selected and addressed in the client's plan of care. Nursing diagnoses are not related to the medical diagnosis or the specific written orders from the primary care provider. Goals can only be established after the problem is identified.

The nurse formulates the following nursing diagnosis: Disturbed Body Image related to decreased ability to cope with surgical removal of right breast. The client refuses to look at surgical site and states, "I'm ugly. My husband will no longer find me desirable." What is the etiology?

Decreased ability to cope with surgical removal of right breast The etiology identifies the factors that contribute to the unhealthy client response or problem. Disturbed Body Image identifies what is unhealthy about the client, indicating the need for change. The client's statements and refusal to look at the surgical site are defining characteristics that validate the existence of the problem.

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 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.

Which of the following is classified as a nursing diagnosis?

Grieving Grieving is a nursing diagnosis per the latest NANDA-I Taxonomy. The other choices are medical diagnoses.

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 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.

Which of the following best defines nursing diagnoses?

Identification of client problems that nurses can treat independently Nursing diagnoses are written to describe client problems that nurses can treat independently. Medical diagnoses identify diseases, whereas nursing diagnoses focus on unhealthy responses to health and illness. Collaborative problems require that a nurse work with other health care professionals, and the treatment comes from nursing, medicine, and other disciplines. Nursing diagnoses identify actual and potential client problems.

In the development of a nursing diagnosis for a client who has cachexia and decreased weight, what would be an appropriate nursing diagnosis?

Imbalanced nutrition: less than body requirements Another common mistake is to write "Lack of adequate nutrition" as the nursing diagnosis. The most appropriate nursing diagnosis would be Imbalanced Nutrition: Less than Body Requirements.

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?

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.

Which is the best example of a nursing diagnosis?

Ineffective Breastfeeding related to latching as evidenced by nonsustained suckling at the breast. Both gastroesophageal reflux and cellulitis are medical diagnoses. Ineffective airway clearance is an appropriate diagnostic label. However, a client not speaking does not match the diagnosis.

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?

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 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 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 sclerae of a 3-day old infant have a yellowish tint and the nurse has just received an order to initiate phototherapy. Which nursing diagnosis will the nurse utilize to plan care for this client?

Neonatal Jaundice The yellow color of the sclera indicates jaundice, which is a common problem in the neonatal period. It is related to difficulties in bilirubin conjugation. "Risk for neonatal jaundice" is inappropriate because the client is already jaundiced. Jaundice signals liver dysfunction, not any problems with vision. (less)

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. 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.

The formulation of nursing diagnoses is unique to the nursing profession. Which statement accurately represents a characteristic of diagnosing?

Nurses write nursing diagnoses to describe client problems that nurses can treat. Data collection leads the nurse to identifying client problems that the nurse is able to treat with planned nursing interventions, which is the focus of nursing diagnoses. Nursing diagnoses change as client goals are met or as new problems develop. Medical diagnoses identify disease processes.

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 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 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 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.

data cluster

grouping of patient data or cues that points to the existence of a health problem.

Which of the following nursing diagnoses is written incorrectly as a result of the health problem and etiology being reversed?

Prolonged Immobility related to impaired skin integrity AEB 1-inch diameter open area on right buttocks surrounded by a 1-inch margin of redness; wound surface clean and beefy red; no drainage or foul odor detected. Impaired Skin Integrity related to prolonged immobility is the correct format. Prolonged immobility contributes (etiology) to impaired skin integrity (problem).

A community group has requested the public health nurse to present a program describing the advised schedule of immunizations for children. To plan for this program, what nursing diagnosis would be most appropriate for the nurse to select?

Readiness for enhanced knowledge: childhood immunizations The community group is asking for information to enhance their health care habits. A wellness diagnosis of Readiness for Enhanced Knowledge is indicated. There is no evidence of ineffective health maintenance practices. There is no evidence that the clients lack immunizations. Risk for complications might result from a lack of immunizations, but that is not the issue being addressed here.

Which of the following errors has the nurse made in formulating the following nursing diagnosis: Prolonged Immobility related to impaired skin integrity AEB one-inch diameter open area on right buttocks surrounded by a one-inch margin of redness; wound surface clean and beefy red; no drainage or foul odor detected.

Reversed the health problem and the etiology The health problem and etiology have been reversed. Impaired Skin Integrity related to prolonged immobility is the correct format.

The care plan for a postoperative client includes a nursing diagnosis of "Risk for urinary retention." The nurse determines that the client has been voiding adequately. What is the nurse's most appropriate action?

Revise the nursing diagnosis because the client's status has changed. The client is no longer exhibiting the health problem of "Risk for Urinary Retention." The nursing diagnosis is no longer valid and must be changed. It is no longer necessary to observe for urinary retention. There is no need for other disciplines so a collaborative problem is unnecessary. Nurses do not consult with physicians about nursing diagnoses; it is the nurse's domain.

Which is an accurately phrased risk diagnosis?

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?

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."

Which nursing diagnosis has the highest priority when caring for an older adult client with Alzheimer disease?

Risk for injury Clients with Alzheimer disease are highly prone to injuries. Risk of injury may also be precipitated by the altered memory. Mortality and morbidity resulting from injury is highest in older age groups. Consequently, it is very important for the nurse to provide a safe and secure environment. Impaired physical mobility, self-care deficit, and impaired memory are also present but are not the highest priority.

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 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 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.

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." The parent's statement of not allowing anyone to help because "they won't do it right" support's the nursing diagnosis of Caregiver Role Strain. The parent's statement indicates an inability to allow help, which will cause mental and physical strain. The other statements indicate a healthy ability to use coping mechanisms to deal with this difficult situation.

The nurse caring for a morbidly obese client formulates the possible nursing diagnosis, "Imbalanced Nutrition: More than Body Requirements related to excessive food intake as evidenced by morbid obesity." In order to assure the accuracy of the diagnosis, which further step must the nurse take?

Validate with the client that excessive food intake is the cause of the client's obesity. The nurse must discuss the diagnosis with the client to ascertain whether or not the diagnosis is correct. There are other causes of obesity, such as a decrease in activity secondary to surgery. In order to plan effective interventions, it is important to determine the correct etiology. Determining the weight loss programs used by the client and the client's motivation to lose weight are important in planning interventions once the cause is determined. The client's usual weight is not relevant; the obesity may be longstanding.

Can a nurse develop a nursing diagnosis when there is not enough evidence to support the presence of a problem, but the nurse would like to gather more evidence?

Yes, this defines a possible nursing diagnosis. This is the definition of a possible nursing diagnosis. The statement is phrased the same way as an actual problem except that the "related to" phrase is "unknown etiology". (less)

What information provides the nurse with accuracy when developing a nursing diagnosis?

a set of clinical cues Each piece of client information is considered a clinical cue; a set of clinical cues forms a cluster that is present if the diagnosis is accurate.

collaborative problems

certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems using physician prescribed and nurse interventions to minimize the complications of the event.

Wellness diagnoses

clinical judgements about a person, group, or community in transition from a specific level of wellness to a higher level of wellness.

Risk nursing diagnoses

clinical judgments that a person, family, or community is more vulnerable to develop the problem that others in the same or similar situation.

The nurse is examining the assessment data of a client and diagnoses a problem of impaired tissue perfusion based on the following assessment data cues: left foot cool and pale with capillary refill > 3 seconds, diminished dorsalis pedis and posterior tibial pulses, client reports cramping pain in left foot. The nurse is doing what?

clustering significant data cues Data clustering involves grouping client data or cues that point to the existence of a client health problem. When formulating a nursing diagnosis, the nurse identifies the client health problem related to an etiology and includes subjective and objective data that support the existence of the actual or potential health problem. The nurse identifies contributing factors in the etiology portion of the nursing diagnosis. The nurse validates the nursing diagnosis, often with the client, after a tentative one is formulated.

Syndrome nursing diagnoses

comprise a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation.

Health problem

condition that necessitates intervention to prevent or resolve disease or illness or to promote coping and wellness.

Which of the following is an example of a nursing diagnosis?

constipation Constipation is a nursing diagnosis included in the Elimination domain. Hypoglycemia, dehydration, and depression are examples of medical diagnoses or medical pathology.

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:

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 writing an actual nursing diagnosis, the nurse includes the etiology that contributes to the current situation. This would be identified as:

related factors. Related factors describe the conditions, circumstances, or etiologies that contribute to the problem. Defining characteristics are the observable "cues" or inferences that cluster as manifestations of an actual illness or wellness health state. The diagnostic label accurately reflects the specific client problem.

The process of nursing diagnosis carries legal implications for nurses. Which of the following legal responsibilities exists for a nurse who has documented a nursing diagnosis related to a client's kidney failure?

reporting signs and symptoms related to the client's kidney failure In producing a nursing diagnosis, a nurse creates accountability for detecting and reporting the signs and symptoms of a medical diagnosis. The nurse is not legally responsible for independently managing or coordinating the client's treatment. Choosing and performing interventions to resolve the condition is primarily within the purview of the physician.

Actual nursing diagnoses

represent problems that have ben validated by the presence of major defining characteristics. This type of nursing diagnosis has four components: label, definition, defining characteristics, and related factor.

Possible nursing diagnoses

statements describing a suspected problem for which additional data are needed.

A nurse is developing a plan of care for a client with a chronic respiratory problem. When developing appropriate nursing diagnoses for this client, the nurse needs to keep in mind that:

the interventions planned must be within the nurse's scope of practice. A nursing diagnosis describes an actual, risk, or wellness-human response to a health problem that nurses are responsible for treating independently. Nursing diagnoses describe the client's response to the disease process, developmental stage, or life process and provide a convenient way to communicate nursing therapies or interventions. Nursing diagnoses carry legal ramifications. Only health care problems within the scope of nursing practice can be identified as nursing diagnoses. A nurse cannot diagnose a medical disease and is not licensed to independently treat such a problem. Although nurses may identify a problem, medical diagnoses require validation by the physician that the problem exists. The main focus of a medical diagnosis is on monitoring for pathophysiologic responses of body organs and systems. Medical diagnoses convey information about signs and symptoms of disease and provide a convenient means for communicating treatment requirements.

Cue

used to denote significant data or date that influence this analysis.

Which actions would take place during the diagnosis stage of the nursing process? Select all that apply.

• "Based on what you have told me, it seems that urinary incontinence is a problem for you. What do you think?" • The nurse determines that the client needs to have a decrease in activity. • The nurse identifies that the client has effectively coped with health stressors in the past. • The nurse identifies that the client who is on strict bed rest is at risk for impaired skin integrity. Diagnosing would include identifying the client's strengths (past effective coping) and potential health problems (risk for impaired skin integrity; risk for injury due to excessive activity) and validating the nursing diagnosis with the client (urinary incontinence). Assisting the client with ambulation would occur in the implementation stage.

The electronic health record enables the nurse to facilitate which nursing actions related to diagnosing? (Select all that apply.)

• Facilitating communication of the patient's actual problems • Making decisions about mutual patient goals and interventions • Determining and documenting when the nursing diagnoses are resolved • Deciding on and documenting new nursing diagnoses • Viewing the patient's ongoing risks The goal of the EHR is to enable the interdisciplinary team caring for the patient to more easily view the patient's risks, health promotion possibilities, and actual long-term care problems. NANDA-I. Viewing the patient's ongoing risks, (e.g. Risk for Aspiration) and problems (e.g. Impaired Gas Exchange) that others have identified and documented is possible when using an EHR.

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. 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.

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 has been accompanied by family members to every appointment. • The client has demonstrated effective coping skills in the past. • The client states a belief in a reward in heaven after death. 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.

A nursing diagnosis of "Ineffective Coping" has been chosen for a client after receiving a diagnosis of prostate cancer. What assessments would the nurse consider as evidence for this diagnosis? Select all that apply.

• The client reports an inability to get adequate restful sleep. • The client has difficulty concentrating on the details of treatment options. • The client states, "I can't handle all of this." Inability to sleep, difficulty concentrating, and the client's verbalization of being overwhelmed are evidence of inability to cope. Seeking information related to the diagnosis and seeking out a spiritual adviser are positive ways of coping.