Professional Nursing EAQ: Ch. 17- Nursing Diagnosis

What is a health promotion diagnosis, according to NANDA-I? It describes a person's readiness to enhance specific health behaviors for well-being. It describes human responses to health conditions that may develop in a vulnerable individual. It describes human responses to health conditions that exist in an individual or community. It is associated with a potential response to the health problem and can change by using specific nursing interventions.

1 A health promotion nursing diagnosis is a type of nursing diagnosis that indicates a person's readiness to enhance specific health behaviors for well-being. A human response to health conditions that may develop in a vulnerable individual is a risk nursing diagnosis. A human response to health conditions that exist in an individual or community is an actual nursing diagnosis. A potential response to the health problem that can change by using specific nursing interventions is a related factor.

A patient diagnosed with pancreatitis complains of pain in the abdomen. The patient has vomited three times, and has a temperature of 101° F. Following an initial interview and assessment, the nurse prepares a nursing care plan. The nurse formulates a diagnosis of acute pain. What could be the related factor for this diagnostic label? Inflammation of the pancreas Fever Distention of the abdomen Vomiting

1 A related factor is the reason for the nursing diagnosis. A change in the related factor tends to bring about a change in the nursing diagnosis and the patient's condition. The patient has acute pain due to inflammation of the pancreas. The related factor is inflammation of the pancreas. The acute pain diagnosis would change if there were a change in the status of the related factor. Fever, distention of the abdomen, and vomiting are not the reasons for the patient's pain. p. 237

What could be the effect of an incorrect nursing diagnosis? It could affect the quality of patient care. It would be corrected automatically in the system. It could affect the patient's cost of treatment. It could produce a psychological disorder in the patient.

1 An incorrect nursing diagnosis may affect the quality of patient care. Incorrect nursing diagnoses are not corrected automatically in the system. The cost of the patient's care is not dependent on the nursing diagnosis. An incorrect nursing diagnosis would not create a psychological disorder in the patient.

Which errors may occur when the nurse makes the nursing diagnosis prior to grouping all data? Errors in data clustering Errors in data collection Errors in the diagnostic statement Errors in interpretation and analysis of data

1 Errors in data clustering occur when the nurse makes the diagnosis prior to grouping all of the data. Errors in data collection occur when the nurse does not have thorough knowledge of the subject or does not possess the proper skill/s related to the subject the nurse is working on. Errors in the diagnostic statement result from inappropriate selection. Errors in the interpretation and analysis of data occur when the nurse is unable to validate data, which can lead to a mismatch between clinical cues and the nursing diagnosis.

The nurse identified that the patient has pain of 7 on a scale of 1 to 10; he winces during movement, and he expresses discomfort over the incisional area. He guards the area by resisting movement. The incision appears to be healing, but there is natural swelling. What would be the P in a three-part nursing diagnostic statement using the PES format? Severe pain Natural swelling Related to incisional trauma Wincing, guarding, restricted turning and positioning

1 The PES format stands for problem (P), etiology or related factor (E), and symptoms or defining characteristics (S). In this case, the problem is severe pain. p. 233

A patient complains of pain when swallowing solid food. The nurse asks the patient if he or she has a history of substance abuse that has caused this pain. What kind of diagnostic error does the nurse make in this scenario? Errors in data collection Errors in data clustering Errors in the diagnostic statement Errors in interpretation and analysis of data

1 The nurse is gathering the wrong information when asking the patient about substance abuse and correlating it with pain when swallowing solid food. Errors in data clustering occur when the nurse clusters prematurely, incorrectly or not at all. Errors in the diagnostic statement occur when the etiology portion of the diagnostic statement goes the nurse's scope of practice. The inability of the nurse to validate data may lead to a mismatch between clinical cues and the nursing diagnosis. This inability to validate leads to errors in interpretation and analysis of data.

The nurse is attending to a patient in a coronary care unit. She is revising the care plan after evaluating the patient outcomes. Which steps of the nursing processes is the nurse performing? Select all that apply. Assessment Evaluation Implementation Planning Diagnosis

1, 2 Assessment is the process by which the nurse collects all the data and revises the care plan after evaluation. Diagnosis, planning, and implementation come later in the process.

Which type of interpretation errors may occur with a nursing diagnosis? Select all that apply. Inaccurate interpretation of cues Use of an insufficient number of cues Failure to consider conflicting cues Failure to validate the nursing diagnosis with the patient Insufficient cluster of cues

1, 2, 3 Inaccurate interpretation of cues, use of an insufficient number of cues, and failure to consider conflicting cues may cause interpretation errors and lead to inaccurate diagnoses. An insufficient cluster of cues does not directly cause interpretation errors but could result in errors in clustering of data. Similarly, failing to validate the nursing diagnosis with the patient does not directly cause interpretation errors but could result in a labeling error.

The nurse is caring for a football player hospitalized for ankle surgery. The patient communicates properly during the interview. The nurse finds a quiver in the patient's voice as he expresses his worry about not being able to play. The nurse observes that the patient has fidgety hands and legs. The nurse concludes that the patient is uncertain about his ability to play postsurgery. Which data cluster helps the nurse determine anxiety is present? Select all that apply. Verbal expression of worry Fidgety hands and legs A quiver in the patient's voice while talking Impending ankle surgery Hospitalization

1, 2, 3 The patient's verbal expression of worry, fidgety hands and legs, and a quiver in voice are defining characteristics of anxiety. A defining characteristic is a clinical criterion that is observable and verifiable. The impending ankle surgery and subsequent hospitalization are related factors and do not define the data cluster, which is a set of signs or symptoms gathered during assessment and grouped together in a logical way.

As per Yura and Walsh, what are the components of the nursing process? Select all that apply. Planning Evaluation Assessment Implementation Nursing diagnosis

1, 2, 3, 4 As per Yura and Walsh, there are four components to the nursing process. They are assessment, planning, implementation, and evaluation. Nursing diagnosis is a part of the nursing process according to most other theorists, but Yura and Walsh do not consider it part of the nursing process.

The nurse is caring for a patient who has been admitted to the hospital with pneumonia. Which assessment findings of the patient can the nurse group together to formulate a data cluster? Select all that apply. Dysuria Wheezing in left lung bases Respiration 20 breaths/minute Weakness of the entire body Shortness of breath with ambulation

2, 3, 5 A data cluster is a set of signs or symptoms gathered during assessment and grouped together in a logical way. Respiratory rate, lung sounds, and shortness of breath are respiratory assessment findings that may be grouped together to manage a respiratory problem. Weakness and dysuria aren't directly related to respiratory issues.

Which diagnostic error may lead to an error in nursing diagnosis? Select all that apply. Failure to seek guidance when the nurse has doubts Premature or early closure of clustering Selection of the wrong diagnostic label Failure to consider conflicting cues Validation of nursing diagnosis with patient

1, 2, 3, 4 Diagnostic errors occur because of errors in data collection, clustering, interpretation, or labeling. When formulating the diagnosis, the nurse should seek guidance from colleagues or senior staff members if there is any doubt. It helps to prevent the incorrect formulation of the nursing diagnosis. Premature or early closure of clustering may lead to exclusion of important patient needs. Selection of a wrong diagnostic label or a label that is not relevant may result in a wrong diagnosis. The nurse who also considers conflicting cues in deciding which diagnostic label to choose interprets cue clusters to make an accurate diagnosis. Validating the nursing diagnosis with the patient helps prevent diagnostic error.

Inaccurate data collection is a source of error in diagnosis. What factors can cause errors in data collection? Select all that apply. Missing data Inaccurate data Disorganization Lack of knowledge or skill Premature or early closure of clustering

1, 2, 3, 4 Missing data, inaccurate data, disorganization, and lack of knowledge or skill can cause errors in data collection. During data collection, the nurse should review the database and decide if it is accurate and complete, which helps in avoiding errors. Premature or early closure can cause errors in clustering, not collection.

What points should the nurse keep in mind when formulating the nursing diagnosis? Select all that apply. Accurately selecting the diagnoses Identifying related factors pertinent to the diagnosis Selecting interventions suited for treating the diagnosed condition Identifying defining characteristics of the diagnosis Properly making medical diagnoses

1, 2, 3, 4 When the nurse makes a diagnosis, it is important to be accurate, to be aware of related factors pertinent to the diagnosis, to plan interventions suited to treating the diagnosed condition, and to be aware of the defining characteristics of the diagnosis. These things are essential for effectively planning the treatment. An accurate nursing diagnosis helps the nurse formulate the appropriate outcome goals for the patient. The defining characteristics are essential components of a nursing diagnosis and give direction to the interventions planned. A medical diagnosis is not carried out by the nurse; rather, it is carried out by the primary healthcare provider.

In the given examples, which nurses are making nursing diagnostic errors? Select all that apply. A nurse listens to lungs for the first time and is not sure if abnormal lung sounds are present. After reviewing objective data, a nurse selects a diagnosis of fear before asking the patient to discuss her feelings. A nurse uses an incorrect diagnostic label. A nurse considers a patient's cultural background when reviewing cues. A nurse prepares to complete a decision on diagnosis and realizes that clinical criteria are grouped incorrectly to form a pattern.

1, 2, 3, 5 A nurse who listens to lungs for the first time and is not sure if abnormal lung sounds are present is displaying a lack of skill, an error in collecting data. After reviewing objective data, a nurse who selects a diagnosis of fear before asking the patient to discuss her feelings is using an insufficient number of cues, which is an error in interpretation. A nurse who uses an incorrect diagnostic label is not accurately identifying the problem, which is a labeling error. A nurse who prepares to complete a decision on diagnosis and realizes that clinical criteria are grouped incorrectly to form a pattern is an example of incorrect clustering, a clustering error.

The nurse is caring for a football player scheduled for ankle surgery. The patient communicates properly during the interview. The nurse finds a quiver in the patient's voice as he expresses his worry about not being able to play. The nurse observes that the patient has fidgety hands and legs. The nurse concludes that the patient is uncertain about his ability to play postsurgery. What interventions should the nurse implement to reduce anxiety in the patient? Select all that apply. Explain the recovery process to the patient. Provide detailed instructions about the surgery. Consult with a psychologist regarding the patient's behavior. Teach postoperative care to the patient and his caregiver. Encourage health-promotion activities such as exercise and routine social activities.

1, 2, 4 Explaining the recovery process and the surgery may reduce the patient's uncertainties regarding the recovery. Teaching postoperative care to the patient and caregiver makes him more self-reliant and may speed his recovery. The patient's anxiety is not pathological; therefore, consulting with a psychologist at this stage is not advisable. Health-promotion activities should be encouraged postoperatively.

The nurse is identifying the related factors by studying a patient's assessment data. According to NANDA-I diagnoses, under which categories should the nurse classify the related factors? Select all that apply. Situational Maturational Psychological Treatment-related Pathophysiological

1, 2, 4, 5 According to NANDA-I diagnoses, related factors come in four categories: situational, maturational, treatment-related, and pathophysiological. A related factor is identified from the patient's assessment data. The related factor is associated with a patient's actual response to the health problem. It can be changed by using specific nursing interventions. According to the NANDA I diagnoses, psychological is not considered a category of related factors.

For a diagnosis of potential for pressure ulcers, what could be the possible related factors? Select all that apply. Age extremes Fluid retention Maturational crisis Impaired sensation Physical immobilization

1, 2, 4, 5 Related factors are associated with a patient's actual or potential response to the health problem and can be changed by specific nursing interventions. Age extremes, fluid retention, impaired sensation, and physical immobilization are related factors that produce a potential for pressure ulcers. Maturational crisis refers to a psychological imbalance in a person going through a transitional period. Maturational crisis is a factor related to anxiety. This would not cause changes in skin integrity.

The nurse is preparing a nursing care plan. Which actions would most likely prevent errors in interpretation when making a nursing diagnosis? Select all that apply. Accurately interpreting cues Using reliable cues Failing to consider conflicting cues Using an insufficient number of cues Considering cultural influences or developmental stage

1, 2, 5 Accurately interpreting and using reliable cues are ways to prevent errors in interpretation while making the nursing diagnosis. The nurse should also consider the influence of culture or developmental stage on the patient's health when formulating a nursing diagnosis. Failure to consider conflicting cues and using an insufficient number of cues may lead to misinterpretation and can lead to errors.

Which steps are essential for decision making in a diagnostic process? Select all that apply. Data clustering Risk nursing diagnosis Formulating the diagnosis Identifying patient health problems Health promotion nursing diagnosis

1, 3, 4 Data clustering, formulating the diagnosis, and identifying patient health problems are the decision-making steps in a diagnostic process. In data clustering, a set of signs or symptoms is gathered during assessment, and the nurse groups the data in a logical way. Formulating a diagnosis involves reviewing all the information. A patient's health problem is identified by the signs and symptoms of the disease. Risk nursing diagnosis and health promotion nursing diagnosis are types of diagnoses.

A patient is anxious about an operation scheduled for the next day. The nurse identifies that the patient is anxious. Which interventions does the nurse use to decrease the patient's anxiety related to surgery? Select all that apply. Provide satisfactory answers to the patient's questions. Instruct the patient to perform range-of-motion exercises. Provide detailed instructions about the recovery process. Provide detailed instructions about the surgical procedure. Provide detailed instructions about discharge planning.

1, 3, 4 Giving satisfactory answers to the patient's questions should make the patient less anxious. Providing detailed instructions about the recovery process and the surgical procedure helps the patient become familiar with the operation and reduces anxiety. Performing range-of-motion exercises is helpful for impaired physical mobility but probably will not decrease anxiety. Providing instructions about discharge planning is unlikely to reduce the patient's anxiety.

The nurse is designing a care plan for a patient admitted to the hospital with pneumonia, the patient is a smoker. The nurse is using the PES format (problem, etiology, and symptom) for formulating nursing diagnoses. Which components can the nurse include in this PES format? Select all that apply. Cough and shortness of breath Medications that the patient must take Dyspnea or difficulty in breathing Problems caused by smoking The diet and regimen to be followed in this disease

1, 3, 4 The components of cough, shortness of breath, and dyspnea or difficulty in breathing constitute the problem and symptoms seen in the patient. "Problems caused by smoking" gives the etiology of the disease. Medications that the person has to take, and the diet and regimen are not part of the PES approach.

The nurse is assessing a patient's data for the related factor of the nursing diagnosis. Which statements are true regarding the related factor? Select all that apply. The related factor is within the domain of nursing practice. The related factor does not always respond to nursing interventions. In the case of a risk nursing diagnosis, the risk factor is the related factor. The related factor is not associated with the patient's actual response to a health problem. The related factor is identified from the patient's assessment data.

1, 3, 5 The etiology or related factor of a nursing diagnosis is always within the domain of nursing practice. In the case of a risk nursing diagnosis, the risk factor is the related factor. The related factors are usually identified from the assessment data obtained from the patient. It is a condition that responds to nursing interventions. The related factor is associated with a patient's actual or potential response to the health problem.

What are the different types of nursing diagnoses, according to NANDA-I? Select all that apply. Risk diagnoses Acute diagnoses Problem-focused diagnoses Chronic diagnoses Health promotion diagnoses

1, 3, 5 There are three types of nursing diagnoses: risk diagnoses, problem-focused diagnoses, and health promotion diagnoses. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. A problem-focused diagnosis describes a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, or community. A health promotion nursing diagnosis is a clinical judgment of a person's, family's, or community's motivation, desire, and readiness to increase well-being. Acute diagnoses and chronic diagnoses are not considered types of nursing diagnoses according to NANDA-I.

The nurse is teaching a group of students about the application of nursing diagnosis to care planning. Which statements indicate effective learning? Select all that apply. "Nursing diagnoses direct the planning process and the selection of nursing interventions." "Nursing diagnoses are a universal means for communication between professional nurses and the public." "A nursing diagnosis would lead the primary health care provider to prescribe a low-carbohydrate diet and medication to a patient with diabetes." "Nursing diagnoses help the primary health care provider determine appropriate nursing interventions and specific outcomes." "Nursing diagnosis of damaged skin directs a nurse to apply a support surface to a patient's bed and initiate a turning schedule."

1, 5 Nursing diagnoses direct the planning process and the selection of nursing interventions. A nursing diagnosis of damaged skin directs a nurse to apply a support surface to a patient's bed and initiate a turning schedule. Nursing diagnoses are a universal means for communication among professional nurses and other health care disciplines, not the public. Medical diagnoses, not nursing diagnoses, lead the primary health care provider to prescribe a low-carbohydrate diet and medication to a patient with diabetes. Nursing diagnoses help nurses, not primary health care providers, to determine nursing interventions and outcomes for the patient's condition.

According to the NANDA International, what are the categories of sources of error that may occur in the nursing diagnostic process? Select all that apply. Implementing Collecting Clustering Evaluating Interpreting

2, 3, 5 Collecting, clustering, and interpreting data are common sources of errors in the nursing diagnostic process, according to NANDA-I. In the data collection process, errors sometimes occur due to a lack of knowledge or skills, inaccurate data, missing data, and disorganization. In clustering, errors may occur due to an insufficient cluster of cues, premature or early closure, and incorrect clustering. In the interpreting process, errors may occur due to inaccurate interpretation of cues, failure to consider conflicting cues, and the use of unreliable or invalid cues. Implementation and evaluation are not included in the nursing diagnostic process.

Following an assessment, the nurse is formulating a nursing diagnosis using the PES format. What does the S in PES stand for? Situation Symptoms Sensitivity Separation of data

2 PES is a three-part nursing diagnosis format. It includes the diagnostic label, etiological statement, and symptoms or defining characteristics. The P stands for problem, the E stands for etiology or related factors, and the S stands for symptoms or defining characteristics. The S does not stand for situation, sensitivity, or separation of data.

Following an assessment, the nurse is formulating a nursing diagnosis using the PES format. What does the P in the acronym PES stand for? Period Problem Prevention Predication

2 The PES format is a nursing diagnosis in three parts. It includes diagnostic label, etiological statement, and symptoms or defining characteristics. The P stands for problem, the E stands for etiology or related factor, and the S stands for symptoms or defining characteristics. The P does not stand for period, prevention, or predication.

The nurse is preparing a diagnostic statement for a patient who has diabetes. What is the most appropriate step the nurse should take in this scenario? The nurse should identify the nursing intervention, not the patient problem. The nurse should identify nursing diagnoses from a cluster of defining characteristics and not just a single symptom. The nurse should identify the medical diagnosis rather than the patient's response when creating the statement. The nurse should identify the treatment or the study itself, rather a problem caused by the treatment or diagnostic study.

2 The nurse should identify nursing diagnoses from a cluster of defining characteristics and not just a single symptom. It is essential for the nurse to identify the patient problem rather than the nursing intervention. It is the priority of the nurse, according NANDA-I, to identify the patient's response rather than identifying the medical diagnosis when creating the nursing diagnostic statement. The nurse should identify the problem caused by the treatment rather than identifying the treatment or the diagnostic study.

Which question does the nurse ask the patient with renal disorder while selecting nursing diagnoses relevant to the patient's culture? "How often do you visit your healthcare setting?" "How does this health problem affect you and your family?" "What should you know before signing an informed consent?" "Do you know about the side effects of the medications that you are using?"

2 The question regarding how the health problem affects the patient and his or her family provides information regarding cultural practices followed by the family. The question regarding visiting the healthcare setting does not provide information about the cultural practices of the patient. Instead, it gives information regarding the patient's health status. The question about informed consent does not provide information regarding the patient's cultural practices. The question regarding the side effects of the medications does not reveal the cultural practices of the family. Instead, this question gives information regarding the patient's knowledge about the medications.

A patient is diagnosed with urinary stress incontinence. The nurse identifies it as which type of diagnosis? Risk diagnosis Actual diagnosis Chronic diagnosis Health promotion diagnosis

2 Urinary stress incontinence is an actual diagnosis. An actual diagnosis describes human responses to health conditions or life processes that exist in an individual, family, or community. A nursing risk diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. A nursing health promotion diagnosis is a clinical judgment of a person's, family's, or community's motivations, desires, and readiness to increase well-being. A chronic diagnosis is not a type of nursing diagnosis.

The nurse is teaching a group of nursing students about the use of standard formal nursing diagnostic statements from the North American Nursing Diagnosis Association-International (NANDA-I). Which statements by a student indicate the need for further learning? Select all that apply. "The nursing diagnostic statements foster the development of nursing knowledge." "The nursing diagnostic statements emphasize following traditional practice guidelines." "The nursing diagnostic statements align the role of the nurses with other health care providers." "The nursing diagnostic statements help the nurses focus on the scope of medical practice as a whole."

2, 3, 4 The standard formal nursing diagnostic statements of the North American Nursing Diagnosis Association-International (NANDA-I) promote the creation of practice guidelines that reflect the essence and science of nursing. They do not necessarily follow the traditional guidelines, which have been handed over through generations. The nursing diagnostic statements do not align the role of the nurse with other health care providers; rather, it distinguishes the nurse's role from that of other health care providers. Nursing diagnostic statements help nurses focus on the scope of nursing practice specifically, not on medical practice as a whole. Therefore any of these three statements made by the nursing student indicates a need for further learning. The nursing diagnostic statement helps to foster the development of nursing knowledge. The nursing diagnostic statement allows nurses to communicate with each other in both written and electronic formats; these are correct statements made by the nursing student and do not indicate the need for further learning.

The nurse in a geriatric clinic collects the following information from an 82-year-old patient and her daughter, the family caregiver. The daughter explains that the patient is "always getting lost." The patient sits in the chair but gets up frequently and paces back and forth in the examination room. The daughter says, "I just don't know what to do because I worry she will fall or hurt herself." The daughter states that, when she took her mother to the store, they became separated, and the mother couldn't find the front entrance. The daughter works part-time and has no one to help watch her mother. Which of the data form a cluster, showing a relevant pattern? Select all that apply. Daughter's concern for mother Pacing Client getting lost easily Daughter working part-time The patient getting up frequently

2, 3, 5 Pacing, getting lost, and hyperactivity are a cluster of defining characteristics that point to the diagnostic label of wandering.

The nurse is teaching nursing students about medical diagnoses. Which statements by the students indicate effective learning? Select all that apply. "Acute pain is a medical diagnosis." "Osteoarthritis is a medical diagnosis." "A medical diagnosis includes the clinical judgment about an individual and his family." "Medical diagnoses are based on the results of diagnostic tests." "A primary healthcare provider is licensed to describe medical diagnoses."

2, 4, 5 A medical diagnosis is the identification of a disease condition based on a specific evaluation of physical signs, symptoms, the patient's medical history, and the results of diagnostic tests. Osteoarthritis and diabetes mellitus are medical diagnoses, because these can be diagnosed by a healthcare provider through diagnostic tests and medical history. Medical diagnoses are based on the results of diagnostic tests. A primary healthcare provider is licensed to describe medical diagnoses and treat diseases. Acute pain is a nursing diagnosis. It can be easily identified by observing a patient's signs and symptoms and does not require any specific diagnostic test. A medical diagnosis does not include a clinical judgment about an individual and his or her family.

The nurse is assessing patients on the unit. What activities would the nurse perform during the diagnostic phase of the nursing process? Select all that apply. Teach the patient about preventative measures. Review information collected about the patient. Find cues and patterns in the patient's data. Make conclusions related to health problems. Implement the care necessary for the patient.

2, 4, 5 A nursing diagnosis is a clinical judgment based on information. The diagnostic process involves reviewing information collected about the patient, finding cues and patterns in the patient's data, and making conclusions related to health problems. These activities help the nurse formulate a diagnosis that focuses on relieving the patient's health problems. Teaching the patient about preventive measures is an activity performed during the planning phase. The nurse implements the care necessary for the patient during the implementation phase.

Which patient-related factors fall under health promotion nursing diagnosis? Select all that apply. The patient follows poor hygiene measures. The patient is willing to eat nutritious foods. The patient shows decreased interaction with society. The patient is ready to increase his or her coping skills. The patient is ready to perform regular exercises.

2, 4, 5 Health promotion nursing diagnosis is a clinical judgment of a patient's motivation, desire, and readiness to increase well-being. While performing health promotion nursing diagnoses, the nurse should focus on the patient's readiness to eat nutritious food and the patient's readiness to enhance coping skills and to perform regular exercise. While performing a risk nursing diagnosis, the nurse would focus on the poor hygiene measures of the patient. While performing the actual nursing diagnosis, the nurse would focus on the patient's social interaction ability.

The nurse completed the following assessment: 63-year-old female patient has had abdominal pain for 6 days. She reports not having a bowel movement for 4 days, whereas she normally has a bowel movement every 2 to 3 days. She has not been hospitalized in the past. Her abdomen is distended. She reports being anxious about upcoming tests. Her temperature was 37° C, pulse 82 and regular, blood pressure 128/72. Which data form a cluster, showing a relevant pattern? Select all that apply. Vital sign results Abdominal distention Age of patient Change in bowel elimination pattern Abdominal pain No history of hospitalization

2, 4, 5 The presence of abdominal pain, distention, and a change in bowel elimination pattern forms a cluster, suggesting an elimination problem.

What is the benefit of an accurate nursing diagnosis? It decreases the side effects of medications. It reduces the cost of treatment to the patient. It helps ensure effective and efficient nursing interventions. It prevents further assessment.

3 An accurate nursing diagnosis helps ensure effective and efficient nursing interventions. Selecting the correct nursing diagnosis is based on proper assessment of the patient and proper analysis of the health problem. It enhances the nursing care provided to the patient. It does not decrease the side effects of the medicines or the cost of treatment. Further assessment after the nursing diagnosis is essential to evaluate the effectiveness of the activities performed.

The nurse reviews data gathered regarding a patient's pain symptoms. The nurse compares the defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as the correct diagnosis. In which option does the nurse avoid an error? Data collection Data clustering Data interpretation Making a diagnostic statement

3 In the review of data, the nurse compares defining characteristics for the two nursing diagnoses and selects one based on the interpretation of data. Making a diagnostic statement is incorrect because the nurse has not included a related factor.

Which term describes data that appear to show some type of patterned relationship with a nursing diagnosis? Data cluster Concept map Related factors Defining characteristic

3 Related factors are data that appear to show some type of patterned relationship with a nursing diagnosis. Data clusters are meaningful and usable patient data that are organized at the initial stage of analysis and interpretation of assessment data. A concept map helps the nurse think critically about the diagnosis of a patient. Defining characteristics of a patient involves observable assessment cues such as patient behavior and physical signs that support each problem-focused diagnostic judgment.

The nurse identified that the patient has pain of 7 on a scale of 1 to 10; he winces during movement, and he expresses discomfort over the incisional area. He guards the area by resisting movement. The incision appears to be healing, but there is natural swelling. What would be the E in a three-part nursing diagnostic statement using the PES format? Severe pain Natural swelling Related to incisional trauma Wincing, guarding, restricted turning and positioning

3 The PES format stands for: problem (P), etiology or related factor (E), and symptoms or defining characteristics (S). In this case, the related factor is the incisional trauma.

The nurse is designing a plan of care for a patient who is has been diagnosed with pneumonia. The nurse determines that the patient is experiencing impaired gas exchange in the lungs. Which components of the assessment data can be part of the related factors for this patient? Select all that apply . Observable cyanosis The family history of the patient Decreased ventilatory effort due to fatigue Accumulation of secretions within the alveoli The diet that the patient should follow for this disorder

3, 4 The related factors are associated with a patient's actual or potential response to a health problem and can changed by using specific nursing interventions. Related factors for a patient with pneumonia and impaired gas exchange include a decreased ventilatory effort and accumulation of secretions at the level of the alveoli. These are both categorized as pathophysiological. Cyanosis is a clinical symptoms that shows evidence of the health problem. The family history of the patient is unrelated to/not associated with the impaired gas exchange in this case. The diet that the patient should follow would be an intervention used to achieve patient outcomes and is not a related factor.

The nurse is assessing the patients on the unit. The nurse identifies some collaborative problems among the patients. What are some examples of collaborative problems? Select all that apply. Cold Nausea Paralysis Hemorrhage Wound infection

3, 4, 5 Collaborative problems are actual or potential physiological complications that the nurse can monitor to detect the onset of changes in the patient's status. Hemorrhage, paralysis, and wound infections are collaborative problems. These problems require nursing and monitoring. Cold and nausea are not collaborative problems because they do not lead to multiple complications.

In the examples given, which nurses are making nursing diagnostic errors? Select all that apply. The nurse who listens to lung sounds after a patient reports difficulty breathing The nurse who considers conflicting cues in deciding which diagnostic label to choose The nurse who is assessing the edema in a patient's lower leg and is unsure how to assess the severity of edema The nurse who identifies a diagnosis based on a single defining characteristic The nurse who identifies a risk-for diagnosis related to a medical diagnosis

3, 4, 5 The nurse assessing the edema in a patient's lower leg who is unsure how to assess the severity of edema fails to validate her assessment findings of edema, either by using a scale to measure the severity or by asking a colleague to validate her findings. The nurse who identifies a diagnosis based on a single defining characteristic prematurely closes clustering, which can lead to an inaccurate diagnosis. Nursing diagnostic statements should not contain medical diagnoses.The nurse who listens to lung sounds after a patient reports difficulty breathing validates findings to make an accurate diagnosis. The nurse who considers conflicting cues in deciding which diagnostic label to choose interprets cue clusters to make an accurate diagnosis. In all cases the related factor or risk factor is a condition for which the nurse can implement preventative measures, not a medical diagnosis.

A patient diagnosed with pancreatitis complains of pain in the abdomen. Following an initial interview and the assessment, the nurse prepares a nursing care plan. Which guidelines should the nurse follow to reduce errors in the diagnostic statement? Select all that apply. Identify medical diagnoses. Identify clinical signs and symptoms. Identify treatable etiology or risk factors. Identify the problems caused by the treatment. Identify the patient's response.

3, 4, 5 The nurse should identify treatable etiology or risk factors, the problems caused by the treatment, and the patient's response in order to reduce errors in the diagnostic statement. Identifying a medical diagnosis does not reduce errors in the diagnostic statement. Similarly, identifying clinical signs and symptoms helps focus treatment but does not reduce diagnostic errors.

Following an initial assessment of a patient, the nurse is formulating nursing diagnoses. Which guidelines should the nurse follow to reduce errors in the diagnostic statement? Select all that apply. Identify medical diagnoses. Identify clinical signs and symptoms. Identify a treatable etiology or risk factor. Identify the problem caused by the treatment, not the treatment itself. Identify the patient's response to the equipment rather than the equipment itself.

3, 4, 5 To reduce errors in a diagnostic statement, the nurse should identify a treatable etiology or risk factor rather than a clinical sign that cannot be treated by a nursing intervention. It would help the nurse choose the appropriate nursing care and minimize the patient's risk. Identification of the problem caused by the treatment helps to direct the nursing care in alleviating it. Identifying the patient's response to the equipment helps to impart appropriate knowledge and alleviate anxiety. Identifying a medical diagnosis may not help; rather identifying the patient's response helps to formulate appropriate nursing diagnosis. Identifying a treatable etiology rather than a clinical sign and identifying a NANDA-I diagnosis would help in reducing errors.

A nurse is teaching a group of nursing students about the use of NANDA-I terminologies in the medical record entry. Which statements made by the student indicate the need for further education? Select all that apply. "NANDA-I diagnoses have a broad literature base." "NANDA-I classifications are widely comprehensive." "NANDA-I diagnoses do not take into consideration evidence-based diagnoses." "NANDA-I diagnoses emphasize precise documentation of health problems." "NANDA-I diagnoses are refined by the primary health care provider on a regular basis."

3, 5 NANDA-I diagnoses are very often based on nursing research and evidence-based practice. NANDA-I diagnoses are continually refined by professional nurses, not primary health care providers. These two answers are inaccurate and indicate a need for further education. NANDA-I diagnoses have a broad literature base, and NANDA-I classifications are considered one of the most comprehensive of all the nursing classifications. NANDA-I diagnoses emphasize providing accurate and precise documentation of health problems. These statements are accurate and do not indicate a need for further education.

On what should the nurse focus when formulating a nursing diagnosis? Disease Complication Physiological event Potential response to a health problem

4 A nursing diagnosis focuses on a patient's potential response to a health problem. A nursing diagnosis provides a basis for selecting, planning, and implementing interventions. Diseases, complications, and physiological events are not the focus when formulating the nursing diagnosis. These components are part of a medical diagnosis.

A group of nurses is organizing an educational session to teach the population of a particular community about the roots of cardiovascular disease and its impact on the human body. Which type of nursing diagnosis is being followed in this scenario? Medical diagnosis Risk nursing diagnosis Problem-focused nursing diagnosis Health promotion nursing diagnosis

4 According to Nursing Diagnosis Association-International (NANDA-I), health promotion nursing diagnosis involves a clinical judgment concerning motivation and desire to increase well-being and actualize human health potential. The education imparted by the group is targeted at motivating and increasing the well-being of the community. A medical diagnosis is a general term that involves the identification of a condition based on a specific evaluation of physical signs and symptoms. It encompasses all kind of diagnosis. NANDA-I defines risk nursing diagnoses as a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions. Problem-focused nursing diagnoses describe a clinical judgment concerning an undesirable human response to a health condition that exists in an individual or a community.

What is a clinical judgment that concerns motivation and desire to increase well-being and actualize human health potential? Medical diagnosis Risk nursing diagnosis Problem-focused nursing diagnosis Health promotion nursing diagnosis

4 Health promotion nursing diagnosis is a clinical judgment concerning motivation and the desire to increase well-being and actualize human health potential. Medical diagnosis is the identification of a disease condition based on a specific evaluation of physical signs and symptoms, a patient's medical history, and the results of diagnostic tests. Risk nursing diagnosis describes a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions or life processes. Problem-focused nursing diagnosis describes a clinical judgment concerning an undesirable human response to a health condition or life process that exists in an individual, family, or community.

The nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is diarrhea related to intestinal colitis. Why is this an incorrectly stated diagnostic statement? It identifies the clinical sign instead of an etiology. It identifies a diagnosis based on prejudicial judgment. It identifies the diagnostic study rather than a problem caused by the diagnostic study. It identifies the medical diagnosis instead of the patient's response to the diagnosis.

4 In this example, intestinal colitis is a medical diagnosis and thus an incorrect diagnostic statement.

Which is an example of an interpreting error in nursing diagnostics? Inaccurate data Disorganization Failure to seek guidance Inaccurate understanding of cues

4 Inaccurate understanding of cues is a diagnostic error related to interpretation. Inaccurate data and disorganization are diagnostic errors related to data collection. Failure to seek guidance is an error related to the labeling of data.

The nurse identified that the patient has pain of 7 on a scale of 1 to 10; he winces during movement, and he expresses discomfort over the incisional area. He guards the area by resisting movement. The incision appears to be healing, but there is natural swelling. What would be the S in a three-part nursing diagnostic statement using the PES format? Severe pain Natural swelling Related to incisional trauma Wincing, guarding, restricted turning and positioning

4 The PES format stands for: problem (P), etiology or related factor (E), and symptoms or defining characteristics (S). In this case, the symptoms are pain reported at a 7 with wincing, guarding, and restricted turning and positioning.

The nurse is teaching a group of nursing students about the application of a nursing diagnosis to nursing practice. Which statement made by a student indicates the need for further teaching? "Nursing diagnosis helps with the identification of patient health problems." "Nursing diagnosis offers an approach to ensure comprehensive nursing assessment." "Research gives backing to nursing diagnoses that are used to identify a patient's health care problem." "Nursing diagnosis improves the selection of nursing interventions by nurses in certain practice settings."

4 The nursing diagnosis improves the selection of nursing interventions by nurses in all practice settings, not specific settings. The nursing diagnosis essentially helps the nurse identify patient health problems. Nursing diagnoses offer an approach to ensure comprehensive nursing assessment. Contributions from research build on the evidence for use of nursing diagnoses in identification of patients' health care problems.