CHapter 15 Diagnosing the point

Which component of a nursing diagnosis gives additional meaning to the nursing diagnosis?

Descriptors Explanation: Descriptors are words used to give additional meaning to a nursing diagnosis through adding conditions and showing relationships between events. The other answers listed are not components of a nursing diagnosis.

Which describes the best approach for the development of nursing diagnoses?

Develop nursing diagnoses from clusters of significant data. Explanation: Nursing diagnoses should always be derived from clusters of significant data, rather than from a single cue. Nursing diagnoses describe client problems that nurses can treat independently and do not require collaboration with other members of the health care team. Therefore, nurses can develop nursing diagnoses without collaborating with physicians or other health care team members.

Which type of health problem requires both physician- and nurse-prescribed actions to address?

Collaborative health problem Explanation: If a problem requires both physician- and nurse-prescribed actions to address, it is by definition a collaborative health problem. The other answers listed are not standard types of health problems

Which would be an appropriate nursing diagnosis for a client with cachexia and decreased weight?

Imbalanced Nutrition: Less than Body Requirements Explanation: The most appropriate nursing diagnosis would be Imbalanced Nutrition: Less than Body Requirements. Anorexia Nervosa is a medical diagnosis. Lack of Adequate Nutrition and Weight Loss are not standard terminology for nursing diagnoses.

A client is caring for the client's mother-in-law, who is an older adult who requires assistance with performing activities of daily living. Which statement by the client would lead the nurse to make a nursing diagnosis of Caregiver Role Strain?

"I just don't have time to take a shower." Explanation: Any of these statements could be a clue to caregiver role strain when clustered with other evidence. However, the inability to care for oneself, such as not taking time for a shower, strongly indicates that this client is not coping well.

The nurse has been assigned to a group of clients. Which client should be the nurse's priority?

A 32-year-old client with a urinary tract infection who is receiving an intravenous antibiotic and reporting swelling in the tongue. Explanation: The client receiving the intravenous antibiotic may be experiencing a possible airway obstruction secondary to an allergic reaction and should be the nurses first priority. Caring for a postoperative client reporting pain is important, but the client is not at risk of further deterioration if not cared for immediately. A client with an oxygen saturation of 91% is within normal limits and not the nurse's priority. A client with a low hemoglobin and symptoms of anemia is not in eminent danger and not the nurse's first priority.

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

A health promotion nursing diagnosis Explanation: The client is seeking information related to healthy practices. Health promotion nursing diagnoses are formulated to assist the client to meet that need. The client has no health problem, risk of a health problem, or possible problem, so a problem-focused, risk, or possible nursing diagnosis would be inappropriate.

A nurse is using Gordon's functional health patterns as an organizing framework for client assessment. The client has significant problems related to breathing, for which the nurse identifies several nursing diagnostic labels, including Ineffective Breathing Pattern and Impaired Gas Exchange. The nurse understands that these nursing diagnoses would be organized under which functional pattern?

Activity-exercise Explanation: Nursing diagnoses involving ineffective breathing pattern and impaired gas exchange would be organized under the pattern of activity-exercise, which addresses the pattern of activity, exercise, leisure, recreation, and activities of daily living. Nutritional-metabolic involves nursing diagnoses associated with weight, eating, fluids, and skin and tissue integrity. Coping-stress tolerance addresses coping, resilience, suicide, and self-mutilation. Cognitive-perceptual addresses pain, neurological issues, impulse control, knowledge, and decision-making.

After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type?

Actual Explanation: "Ineffective Airway Clearance related to thick tracheobronchial secretions" is an actual nursing diagnosis, because it describes a human response to a health problem that is being manifested. A health promotion nursing diagnosis is a diagnostic statement that describes the human response to levels of wellness in an individual, family, or community that has a potential for enhancement to a higher state. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. A possible nursing diagnosis is made when not enough evidence supports the presence of the problem, but the nurse concludes that it is highly probable and wants to collect more information.

A nurse is caring for an older adult client who is scheduled for a cystoscopy the next day to determine the cause of an overdistended bladder. The client expresses being nervous and informs the nurse that this the first time that the client has been admitted to a health care facility for an illness. Which diagnostic label would the nurse use to formulate the nursing diagnosis?

Anxiety Explanation: Anxiety is an accurate diagnostic label, the name of the nursing diagnosis as listed in the taxonomy. It is also the only option related to the client's experience to the new experience of being hospitalized. Compromised is a descriptor; physical immobility is a risk factor; overdistension is a related factor.

The care plan for a client who has been frequently admitted to the hospital for exacerbation of chronic obstructive pulmonary disease (COPD) includes a nursing diagnosis of "Noncompliance related to lack of knowledge as evidenced by frequent admissions to the hospital." What is the most appropriate method for the nurse to use to validate the nursing diagnosis?

Assess the client's knowledge of COPD. Explanation: The nurse has theorized that the client is noncompliant because of a lack of knowledge. Therefore, the nurse must assess what knowledge the client has. The severity of the client's illness has no bearing on how compliant the client is or on the client's level of knowledge about the disease. The client's financial resources and access to health care may be other causes of noncompliance but do not support the nurse's theory of the client's lack of knowledge leading to noncompliance.

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

Client Explanation: After selecting a nursing diagnosis, the nurse should validate it with the client. Validation legitimizes the diagnosis and helps to discover its significance for the client. There is no need to validate the nursing diagnosis with another staff nurse, the client's health care provider, or the unit's nurse manager.

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 Explanation: 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.

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. Explanation: 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. Although assessment--collecting subjective and objective client data--is necessary before developing nursing diagnoses, this assessment does not necessarily have to be a focused assessment.

A client reports not having a bowel movement for 7 days, followed by a day of small, loose stools. How does the nurse define the health problem?

Constipation related to irregular evacuation patterns Explanation: This client is experiencing constipation, which is having infrequent or difficult bowel movements, which the nurse believes to be caused by an irregular evacuation pattern--not having a bowel movement for 7 days. There is no evidence that the client needs, much less is ready for, enhanced nutrition related to constipation or that, by implication, that the client's constipation is caused by poor nutrition. There is no evidence that the client is experiencing bowel incontinence, depression, or diarrhea.

A newly graduated nurse is unable to determine the significance of data obtained during an assessment. What would be the nurse's most appropriate action?

Consult with a more experienced nurse. Explanation: A newly graduated nurse does not have the experience to interpret all data. The nurse must recognize when a consult with a more experienced nurse is needed. There is no evidence that the nurse needs to collect more data. The nurse must document the data, but if the data are significant and the nurse does not recognize this and takes no action, it could harm the client. There is no need to contact the health care provider at this time.

A client with advanced Alzheimer's disease has a nursing diagnosis of "Risk for Aspiration." What would the nurse select as an appropriate etiology for this diagnosis?

Decreased level of consciousness Explanation: The appropriate etiology would deal with the client's decreased level of consciousness. Any client with a decreased level of consciousness is at risk for aspiration. Alzheimer's disease is an inappropriate etiology because it is a medical diagnosis. A choking episode would be evidence of a potential for aspiration. Fluids entering the airway is the definition of aspiration.

A client undergoing chemotherapy for breast cancer has lost all 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 Explanation: The client has a problem with body image because of the loss of 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.

A client has been admitted with symptoms of shortness of breath on exertion, edematous lower extremities, extreme fatigue, and hypertension. Which are priority nursing diagnoses? Select all that apply.

Excess Fluid Volume Decreased Cardiac Output Activity Intolerance Explanation: The client's excess fluid volume and activity intolerance can be addressed independently by the nurse, so those diagnoses are appropriate. Decreased cardiac output is a nursing diagnosis and may be related to the client's signs and symptoms. Hypertension and congestive heart failure are medical diagnoses.

A nurse documents the following nursing diagnosis on a client's plan of care: "Fluid Volume Deficit related to gastrointestinal upset from food poisoning as evidenced by vomiting and diarrhea for the past three days, slow skin turgor, and weight loss." The nurse identifies which part of the statement as the etiology?

Gastrointestinal upset from food poisoning Explanation: The etiology identifies the physiological, psychological, sociological, spiritual, and environmental factors believed to be related to the problem as either a cause or a contributing factor. The problem is fluid volume deficit. Vomiting and poor skin turgor are defining characteristics.

A nurse documents the following nursing diagnosis on a client's plan of care: "Readiness for Enhanced Breast-Feeding." The nurse has identified which type of nursing diagnosis?

Health promotion Explanation: A health promotion nursing diagnosis is a clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential. These responses are expressed by a readiness to enhance specific health behaviors and can be used in any health state. A problem-focused nursing diagnosis is a clinical judgment concerning an undesirable human response to a health condition or life process that exists in an individual, family, group, or community. A risk nursing diagnosis is 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. A syndrome nursing diagnosis is a clinical judgment concerning a specific cluster of nursing diagnoses that occur together and are best addressed together and through similar interventions.

The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping?

Health promotion nursing diagnosis Explanation: Readiness for Enhanced Coping is an example of a health promotion nursing diagnosis. Two cues must be present for a valid health promotion nursing diagnosis: a desire for a higher level of wellness and an effective present status or function. An actual nursing diagnosis represents a problem that has been validated by the presence of major defining characteristics. A risk nursing diagnosis is a clinical judgment that concludes that an individual, family, or community is more vulnerable to develop the problem than are others in the same or a similar situation. A syndrome nursing diagnosis comprises a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation.

When developing a nursing diagnosis for a client, which should the nurse do first?

Identify the significant data Explanation: The first step in developing a nursing diagnosis is to look at the data for significant cues. After identifying significant data or cues, the nurse then groups the cues together to form meaningful clusters that describe specific client problems. Cluster interpretation involves synthesizing the cue clusters, to see the whole picture and attach meaning to the cluster. After developing the nursing diagnosis, the nurse should validate it with the client.

A nurse is caring for a toddler who has been treated on two different occasions for lacerations and contusions due to the parents' negligence in providing a safe environment. What is an appropriate nursing diagnosis for this client?

High Risk for Injury related to unsafe home environment Explanation: The nursing diagnosis "High Risk for Injury related to unsafe home environment" is appropriate because it contains the NANDA-I nursing diagnosis problem statement and the etiology of the problem. High Risk for Injury related to abusive parents is accusatory and may not be accurate. High Risk for Injury related to impaired home management does not accurately identify the etiology of the problem. Child Abuse is not a NANDA-I approved nursing diagnosis.

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 Explanation: 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.

When developing nursing diagnoses, the nurse should focus on which area?

Human responses to actual or potential health problems Explanation: The main focus of nursing diagnoses is on monitoring human responses to actual or potential health problems, whereas the main focus of medical diagnoses and collaborative problems is on monitoring the pathophysiological responses of body organs or systems. Actions to be initiated for treatment are the main focus for interventions or treatment. Collaboration with the physician to validate the problem reflects medical diagnoses or collaborative problems.

A nurse, who is caring for a client admitted to the patient care unit with acute abdominal pain, formulates the care plan for the client. Which nursing diagnosis is the priority for this client?

Impaired Comfort Explanation: Acute pain in the abdomen disturbs all the systems of the body. Relieving the pain should be the nurse's first priority. According to Maslow, physiologic needs are the highest priority. The client may have Disturbed Body Image, Disturbed Sleep Pattern, or Activity Intolerance, but all these are secondary to pain.

A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain, which is interfering with the client's ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records?

Impaired Physical Mobility related to pain Explanation: "Impaired Physical Mobility related to pain" is the correct nursing diagnosis because it consists of an accurate descriptor, diagnostic label, and related factor. "Ineffective Movement related to arthritis" is an incorrect entry because the descriptor is incorrect and the diagnostic label is not approved. "Impaired Movements due to pain" is an inaccurate entry because the descriptor is inaccurate and the related factor is not written using approved words. "Ineffective Physical Mobility due to pain" has an erroneous diagnostic label and the related factors are written incorrectly.

The nurse is caring for a client who is postoperative day 2 after a total knee replacement. The client refuses to ambulate when the physiotherapist arrives to the unit. The client states, "It is too soon to get up and walk. I am worried my incision will tear open." The nurse correctly documents the problem-focused nursing diagnosis using which statement?

Impaired physical mobility related to anxiety as evidenced by expressed fear of postoperative complications. Explanation: A problem-focused nursing diagnostic statement contains three parts, sometimes referred to as "PES." P: Name of the health-related issue or problem as identified in the NANDA-I list. E: Etiology (the problem's cause). S: Signs and symptoms, also called defining characteristics. The name of the nursing diagnosis is linked to the etiology with the phrase "related to," and the signs and symptoms are identified with the phrase "as evidenced by." The client's ability to ambulate when expected postoperatively is impaired by anxiety related to fear of postoperative complications. A statement regarding an actual client problem must include what the problem is related to and what evidence the nurse has to indicate that there is a problem. The client is having actually anxiety and is not at risk for it. Beginning the statement with "at risk for" would make the statement inaccurate. The client has not demonstrated a knowledge deficit about normal postoperative activities. The barrier to ambulating is fear and anxiety. There is no evidence to indicate that the client has a disturbed body image. The nurse would have to assess further to confirm this is accurate and include this as evidence in the problem-focused statement.

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 Explanation: Because 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.

The nurse is assessing a 3-week-old infant who has not gained weight since birth. The infant's bowel sounds are present in all quadrants and breath sounds are clear to auscultation. The infant's mother reports that the child cries much of the night but sleeps better in the daytime. The mother reports that the child only breastfeeds about four times in a 24-hour period and that the mother doesn't seem to have much milk. Which nursing diagnosis would be of highest priority for this client?

Ineffective Breastfeeding Explanation: The frequency of breastfeeding is the likely cause of the infant's inability to gain weight. Feeding should be priority for a newborn. Although the infant does demonstrate an impaired sleep pattern and impaired comfort, these are not as important as the infant's inability to gain weight. There is no evidence that the mother is at risk for impaired parenting.

Which is the best example of a nursing diagnosis?

Ineffective Breastfeeding related to latching as evidenced by nonsustained suckling at the breast. Explanation: Ineffective breastfeeding contains all the correct and necessary components of a nursing diagnosis. 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 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. Explanation: 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 client with diabetes mellitus has been admitted to the hospital in diabetic ketoacidosis. During the admission assessment of the client, the nurse learns that the client is not following the prescribed therapeutic regimen. The client states, "I don't really have diabetes. My doctor overreacts." What is the most appropriate diagnosis for this client's health problem?

Ineffective Health Maintenance related to client's denial of illness Explanation: The most appropriate diagnosis is Ineffective Health Maintenance related to client's denial of illness. The data point to the fact that the client is not managing the diabetes, since the client denies that a problem exists. The client is at risk for unstable blood glucose, but the client's denial is the underlying problem. Risk for Injury relates to safety issues. It is also inappropriate documentation to say the client is "mismanaging" the illness. Ineffective Coping could be an appropriate diagnosis, but the client is not "unable" to manage the illness, just unwilling.

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 Explanation: 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.

What association meets every 2 years to further progress in defining, classifying, and describing nursing diagnoses?

NANDA-International (NANDA-I) Explanation: NANDA-International (NANDA-I) conferences are held every 2 years, and much progress continues to be made in defining, classifying, and describing nursing diagnoses. The National League for Nursing (NLN) is a national organization for faculty nurses and leaders in nurse education. It offers faculty development, networking opportunities, testing services, nursing research grants, and public policy initiatives to more than 40,000 individual and 1,200 education and associate members. The Canadian Nurses Association is the national professional association representing over 139,000 registered nurses in Canada. The Canadian Medical Association is a national, voluntary association of physicians that advocates on behalf of its members and the public for access to high-quality health care and provides leadership and guidance to physicians.

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. Explanation: 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.

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 Explanation: 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 Explanation: 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 the only life-threatening problem among the answer options, so it must be the priority.

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 Explanation: The community group is asking for information to enhance their health care habits. A health promotion 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 is a legal responsibility of 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 Explanation: 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.

Which action is a priority role of the nurse when caring for a client with collaborative problems?

Reporting trends that suggest the development of complications Explanation: For a client with collaborative problems, the nurse should report trends that suggest the development of complications to bring to notice the need for collaborative intervention for the client. Collaborative problems are physiologic complications that require both nurse- and physician-prescribed interventions. Actions that exclude members of other disciplines are not characteristic of collaborative problem management. The development of complications is a priority over assessment of the client's knowledge of risk factors, even though the nurse must assess these.

A client admitted for a surgical procedure tells the nurse, "I am very worried because I am allergic to latex. I want to make sure that everyone knows this." To ensure the safety of the client, which nursing diagnosis should the nurse assign to this client and address in the care plan?

Risk for Allergy Response related to latex allergy Explanation: To ensure the safety of the client, the nurse should address the risk for an allergic response due to the client's latex allergy. Anxiety refers to a vague feeling of dread; however, the client is responding with fear to a very real threat. There is no evidence that the client does not understand the surgical procedure. Risk for Injury is not an appropriate diagnosis, because it does not adequately address the specific health problem.

Which is an accurately phrased risk nursing diagnosis?

Risk for Falls related to altered mobility Explanation: Risk for Falls related to altered mobility is an accurately phrased risk nursing diagnosis. It is a two-part statement that contains the diagnostic statement (Risk for Falls) and risk factors (altered mobility).Two of the options (Risk for Impaired Coping and Risk for Fluid Volume Excess) incorrectly pair actual presenting manifestations, also called defining characteristics (client crying, consuming 3 L of soda), with a risk statement. Another option (Risk for Pain After Surgery) does not include a risk factor.

Which statement appropriately identifies a risk nursing diagnosis for a client who is confined to bed?

Risk for Impaired Skin Integrity related to bed rest Explanation: A 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." The client in this scenario is most at risk for skin breakdown related to prolonged confinement to bed; however, proactive and continued nursing interventions can reduce this risk. Ineffective Airway Clearance and Immobility are not risk nursing diagnoses but actually nursing diagnoses, as they describe problems that already exist. Potential for Pneumonia is not a properly worded risk nursing diagnosis; "Risk for" should be included rather than "Potential for."

A client with HIV has been admitted to a health care facility. Which nursing diagnosis should be the priority, keeping in mind the client's condition?

Risk for Infection Explanation: Clients with HIV have decreased immunity and are prone to infections. Infection in a client with HIV is life-threatening, because it makes the client vulnerable to other infections, and also impairs their already weakened immune functions. Clients with HIV may not have problems with other activities and food. They may often feel depressed, but this is not the highest priority.

An older adult client's venous ulcer has become foul-smelling after the client began using strips of a sheet to dress the wound due to running out of sterile dressing supplies. How should the nurse document a nursing diagnosis statement related to this client's circumstances?

Risk for Infection related to knowledge deficit Explanation: Risk for Infection related to knowledge deficit is the correct answer. The client's use of nonsterile items to dress a wound clearly indicates a lack of knowledge. Acute confusion describes a change in cognition, not an inappropriate action. A risk for infection does not cause a knowledge deficit. Indeed sepsis can result from an infection, but infection is a medical diagnosis, not a nursing diagnosis.

A nurse is educating a client about care to be taken in nephrotic syndrome. The client expresses that the education is of no use because the disease is not curable. What nursing diagnosis should the nurse formulate with regard to the client's concern?

Risk for Powerlessness Explanation: The most appropriate nursing diagnosis for the client is the Risk for Powerlessness. The client feels that the disease is not under the client's control and any personal efforts will not affect outcome. Disturbed Body Image is not an appropriate answer because the client does not seem to be concerned about the appearance of the body. Impaired Comfort is also not an appropriate nursing diagnosis because the client does not demonstrate any sign of discomfort. There is not enough indication that the client is at risk for suicide.

The nurse is formulating nursing diagnoses pertaining to a client with pancreatic cancer. Which factors should 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 states a belief in a reward in heaven after death. The client has demonstrated effective coping skills in the past. Explanation: The client's support by 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 the client's 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." Explanation: 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.

The nurse has identified a nursing diagnosis of "Risk for Impaired Parenting" for a client who has recently learned of being pregnant. 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." Explanation: It is not unusual to feel unprepared to care for a baby. However, this warrants the nurse's attention because there is an associated risk of impaired parenting. Being shocked about the pregnancy and being aware of the need to make changes in one's life are normal reactions to finding out about a pregnancy and do not necessarily indicate future problems. The nurse must work with the client about communication with family, but this does not necessarily mean that the client's parenting will be compromised.

The nurse caring for a client diagnosed with melanoma has identified a nursing diagnosis of "Ineffective Coping." What subjective assessment data would provide evidence for this nursing diagnosis?

The client's report of increased consumption of alcohol Explanation: The client's increased consumption of alcohol is an unhealthy coping mechanism. The client's other statements indicate healthy ways of dealing with the illness.

The nurse has selected a nursing diagnosis of "Impaired Home Maintenance" for an older adult client. What assessment data would evidence this diagnosis?

The nurse observes unsafe conditions in the client's home. Explanation: The observation of unsafe conditions indicates that the client is not effectively maintaining the home. The client's confusion may be a temporary condition and does not take into account any help the client has in maintaining the home. Living with family members provides a source of support for the client, which should assist in home maintenance. The client's distaste for housework does not mean that the client is not maintaining the home.

When reviewing the client's history, the nurse notes that the client's last documented bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "Constipation," what assessment must the nurse make?

The nurse should determine the client's normal bowel elimination pattern. Explanation: To validate the diagnosis, the nurse must determine what is normal for the client. Dietary habits may contribute to constipation, but the nurse must first confirm that the client is actually constipated. Likewise, bowel sounds might help explain the cause of constipation, but the nurse should first confirm that the client is constipated. There is no standard elimination pattern; it is highly individualized.

During morning report, the night nurse tells the day nurse that the client refused to allow the technician to draw blood for laboratory testing. What step would be essential for the day nurse to complete before selecting a nursing diagnosis to address this issue?

The nurse should determine the reason for the client's refusal. Explanation: Before addressing the issue, the nurse must determine why the client refused the lab draw. It is essential to know the cause before planning how to address the issue. It is immaterial how long the client has been in the hospital, what laboratory tests are critical, or what the client's last results were.

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." Explanation: The parent's statement of not allowing anyone to help because "they won't do it right" supports 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.

Which error has the nurse made in formulating the nursing diagnosis: Pain related to nurse failing to administer pain med in a timely manner as evidenced by client pain rating of 7 out of 10, client guarding abdominal incision, client ambulating slowly?

Used legally inadvisable terms Explanation: The etiology of the nursing diagnosis is written in legally inadvisable terms and implies nursing negligence. This nursing diagnosis is not imprecise; it identifies the appropriate client problem--pain--and specifies the etiology and defining characteristics. This nursing diagnosis does not use a medical diagnosis; "pain" is a standard client problem to include in a nursing diagnosis. The defining characteristics are included: "as evidenced by client pain rating of 7 out of 10, client guarding abdominal incision, client ambulating slowly."

When used in a nursing diagnosis, the descriptor "impaired" has which meaning?

Weakened or damaged Explanation: The descriptor "impaired" means weakened or damaged, such as in reference to a faculty or function. The descriptor "complicated" means consisting of many interconnecting parts or elements. The descriptor "delayed" means late, slow, or postponed. The descriptor "imbalanced" means lack of proportion or relation between corresponding things.

The nurse recognizes that health problems that the nurse can address by independent nursing interventions are called:

actual or potential nursing diagnoses. Explanation: 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 to assist the client in resolving the health issue. Dependent nursing diagnoses require a specific written order from the primary health care provider for a nurse to address. 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.

The nurse is caring for a client with right-sided weakness after having a cerebrovascular accident (CVA). While conducting the head-to-toe assessment, the nurse notices the client has redness around the right elbow. When developing the client's care plan, which problem-focused nursing diagnosis will the nurse include?

impaired skin integrity of right elbow related to immobility due to right-sided weakness Explanation: A nursing diagnosis is a health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures. It is an exclusive nursing responsibility. Nursing diagnoses are categorized into four groups: problem-focused (formerly called actual); risk; syndrome; and health promotion. The client's elbow joint skin redness is considered an actual problem based on the various risk factors present. When developing a problem-focused nursing diagnosis, the nurse will indicate that skin integrity is actually impaired and this impairment is related to immobility leading to friction on the joint as a result of the client's right sided weakness. Any nursing diagnosis with the terms "risk for" indicate that an actual problem does not yet exist but careful observation and monitoring using focused assessment must be carried out in order to prevent a problem for which risk factors are present. It is not within the nurse's scope of practice to state the medical diagnosis within the nursing diagnosis. Nursing develops problem-focused statements based on presenting signs and symptoms that can be addressed by employing nursing interventions.

A nurse makes a nursing diagnosis of Constipation after a client reports not defecating on the last trip to the bathroom. The nurse has no other information on the client's defecation history. This is an example of:

premature closure. Explanation: 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 a diagnosis. Inconsistent cues occur when the meaning attached to one cue may be altered based on another cue. The nurse in this case only considered one cue, so inconsistent cues could not be the correct answer. Clustering of cues is a clustering of data; this nurse has only one cue, so the nurse cannot cluster data or interpret data clusters.

When developing an appropriate nursing diagnosis, the nurse needs to keep in mind that:

the interventions planned must be within the nurse's scope of practice. Explanation: A nursing diagnosis describes an actual, risk, or health promotion 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 may be identified as nursing diagnoses. A nurse may not diagnose a medical disease and is not licensed to independently treat such a problem. Medical diagnoses, not nursing diagnoses, require validation by the physician that the problem exists, are focused on pathophysiologic responses of body organs and systems, and convey information about signs and symptoms of disease.