Sherpath - Ch. 17 Nursing Diagnosis

Which factor can cause errors in data collection? Select all that apply. Missing data Inaccurate data Disorganization Lack of knowledge of skill Premature or early closure of clustering

- Missing data - Inaccurate data - Disorganization - Lack of knowledge of skill Rationale: Premature or early closure can cause error in clustering, not collection.

Which problem is a collaborative problem? Select all that apply. Cold Nausea Paralysis Hemorrhage Wound infection

- Paralysis - Hemorrhage - Wound infection

As per Yura and Walsh, which describes a component of the nursing process? Select all that apply. Planning Evaluation Assessment Implementation Nursing diagnosis

- Planning - Evaluation - Assessment - Implementation Rationale: Per Yura and Walsh there are four components

Which type of interpretation error 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

- Inaccurate interpretation of cues - Use of an insufficient number of cues - Failure to consider conflicting cues

Which term best describes data that appear to show some type of pattered relationship with a nursing diagnosis?

related factors

Which question does the nurse ask the patient with a renal disorder while selecting nursing diagnoses relevant to the patient's culture?

"How does this health problem affect you and your family?"

Which statement by the students indicates effective learning regarding medical diagnoses? Select all that apply. "Acute pain is a medical diagnosis." "Osteoarthritis is a medical diagnosis." "A medical diagnosis includes the clinical judgment about and individual and his or her family." "Medical diagnoses are based on the results of diagnostic tests." "A health care provider is licensed to describe medical diagnoses."

- "Osteoarthritis is a medical diagnosis." - "Medical diagnoses are based on the results of diagnostic tests." - "A health care provider is licensed to describe medical diagnoses."

Which statement made by a student indicates the need for further teaching regarding the application of nursing diagnoses to clinical practice?

"Nursing diagnoses improve the selection of nursing interventions by nurses in certain practice settings."

Which statement by a student indicated the need for further learning regarding the use of a standard formal nursing diagnostic statement from NANDA-I? Select all that apply. "These statements foster the development of nursing knowledge." "Nursing diagnoses emphasize following traditional practice guidelines." "These statements align the role of the nurses with other health care providers." "Nursing diagnoses help the nurses focus on the scope of medical practice as a whole." "These statements allow nurses to communicate among themselves in both written and electronic formats."

- "Nursing diagnoses emphasize following traditional practice guidelines." - "These statements align the role of the nurses with other health care providers." - "Nursing diagnoses help the nurses focus on the scope of medical practice as a whole."

In the given examples, which nurse is making nursing diagnostic error? Select all that apply. A nurse listens to the 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 his or her feelings. A nurse uses and incorrect diagnostic label. A nurse considers a patient's cultural background when reviewing cues. A nurse selects a diagnostic label based on clinical criteria that are grouped incorrectly.

- A nurse listens to the 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 his or her feelings. - A nurse uses and incorrect diagnostic label. - A nurse selects a diagnostic label based on clinical criteria that are grouped incorrectly.

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

- A related factor is within the domain of a nursing practice. - In the case of a risk nursing diagnosis, a risk factor is the related factor. - A related factor is identified from the patient's assessment data.

Which point would the nurse consider 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 diagnosis

- 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

Which related factor could be used for a potential diagnosis for pressure ulcers? Select all that apply. Age extremes Fluid retention Maturational crisis Impaired sensation Physical immobilization

- Age extremes - Fluid retention - Impaired sensation - Physical immobilization Rationale: Related factors are associated with a pt's actual or potential response to the health problem and can be changes by specific nursing interventions. Maturational crisis is a factor related to anxiety.

According to NANDA-I, which category of sources of error may occur in the nursing diagnostic process? Select all that apply. Implementing Collecting Clustering Evaluating Interpreting

- Collecting - Clustering - Interpreting

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 for formulating nursing diagnoses. Which component 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

- Cough and shortness of breath - Dyspnea or difficulty in breathing - Problems caused by smoking

Which step is 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

- Data clustering - Formulating the diagnosis - Identifying patient health problems

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 component 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 caused by fatigue Accumulation of secretions within the alveoli The diet that the patient should follow for this disorder

- Decreased ventilatory effort caused by fatigue - Accumulation of secretions within the alveoli

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 intervention would 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.

- Explain the recovery process to the patient. - Provide detailed instructions about the surgery. - Teach postoperative care to the patient and his caregiver.

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

- 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

A patient is anxious about an operation scheduled for the next day. Which intervention 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.

- Provide satisfactory answers to the patient's questions. - Provide detailed instructions about the recovery process. - Provide detailed instructions about the surgical procedure.

The nurse is assessing patients on the unit. Which activity 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

- Review information collected about the patient - Find cues and patterns in the patient's data - Make conclusions related to health problems

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

- Risk diagnosis - Problem-focused diagnosis - Health promotion diagnosis

According to the NANDA-I diagnoses, under which category would the nurse classify related factors? Select all that apply. Situational Maturational Psychological Treatment-related Pathophysiological

- Situational - Maturational - Treatment-related - Pathophysiological Rationale: According to NANDA-I diagnoses, related factors come in four categories (the ones above).

Which related factor falls 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 exercise.

- The patient is willing to eat nutritious foods. - The patient is ready to increase his or her coping skills. - The patient is ready to perform regular exercise.

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 and error?

Data interpretation

A patient complains of pain when swallowing solid food. The nurse asks the patient if he or she has history of substance abuse that has caused this pain. Which diagnostic error does the nurse make in this scenario?

Error in data collection

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

Errors in data clustering

A group of nurses is organizing an education session to teach the population of a particular community about the roots of cardiovascular disease and its effect on the human body. Which type of nursing diagnosis is being followed in this scenario?

Health promotion nursing diagnosis

Which clinical judgment concerns motivation and desire to increase well-being and actualize human health potential?

Health promotion nursing diagnosis

What action would the nurse take when preparing a diagnostic statement for a patient who has diabetes?

Identify nursing diagnoses from a cluster of defining characteristics and not just a single symptom.

Which nursing diagnosis will the nurse select upon auscultating wheezing breath sounds in a patient with exercise-induced asthma when the clinic uses the ICNP terminology system?

Impaired respiratory system

An incorrect nursing diagnosis could lead to which factor?

It could affect the quality of patient care.

Which statement describes a health promotion diagnosis, according to NANDA-I?

It describes a person's readiness to enhance specific health behaviors for well-being.

An accurate nursing diagnosis leads to which benefit?

It helps ensure effective and efficient nursing interventions.

Which word does the P in the acronym PES stand for?

Problem P - Problem E - Etiology or related factor S - Symptoms or defining characteristics

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. Which component is the P in a three-part nursing diagnostic statement using the PES format?

Severe pain

Which word does the S in PES stand for?

Symptoms

The nurse identified that the patient has pain of 7 on a scale from 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. Which component is the S in a three-part nursing diagnostic statement using the PES format?

Wincing, guarding, and restricted turning and positioning P: severe pain E: related to incisional trauma S: pain reported at a 7 with wincing, guarding, and restricted turning and positioning

Which describes an example of an interpreting error in nursing diagnostics?

inaccurate understanding of cues