Chapter 4. Nursing Process: Diagnosis

What is wrong with the following diagnostic statement? "Impaired Physical Mobility related to laziness and not having appropriate shoes." The statement is 1) Judgmental 2) Too complex 3) Legally questionable 4) Without supportive data

ANS: 1 "Lazy" implies criticism of the client and therefore is judgmental. There need to be several (certainly more than two) etiological factors for the statement to be complex. There is no blame implied or harm resulting, so the statement is not legally questionable. There is no minimum "amount" of supportive data for a diagnosis and the stated etiology related to the nursing diagnosis. No supportive data are given in the stem of the question, so you could not choose "lack of data" as the best answer because all the options lack data as far as you can tell from the information given in the question. In addition, it is not necessary to include supportive data in the diagnostic statement (although some do prefer to use "A.M.B." and include defining characteristics). PTS:1DIF:ModerateREF:p. 74 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis

Which of the following is an example of a cluster of related cues? 1) Complains of nausea and stomach pain after eating 2) Has a productive cough and states stools are loose 3) Has a daily bowel movement and eats a high-fiber diet 4) Respiratory rate 20 breaths/min, heart rate 85 beats/min, blood pressure 136/84

ANS: 1 A cue is an unhealthy response; a cluster of cues consists of cues related to each other. Productive cough and loose stools are abnormal findings but are not obviously or usually related to each other. Daily bowel movement and high-fiber diet are related but normal responses. The vital signs are also within normal limits. PTS:1DIFgrinifficultREF: pp. 62 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

The diagnostic label, or patient problem, is used primarily to suggest 1) Client goals 2) Cue clusters 3) Interventions 4) Etiology

ANS: 1 As a general rule, the problem suggests goals for client outcomes. The etiology suggests interventions. Cue clusters support whether the correct nursing diagnosis has been identified. PTS: 1 DIF: Moderate REF: p. 73 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall

Which of the following is a criticism of standardized nursing diagnoses developed by NANDA-I? 1) There is little research to support nursing diagnoses labels. 2) A perfect nursing diagnosis must be written for it to be useful. 3) They are not included in all states' nurse practice acts. 4) Other professions do not recognize nursing diagnoses.

ANS: 1 Best practice is evidence-based practice; that is, it is developed through sound, scientific research. Research is currently being conducted, but many of the diagnoses are not research based. A perfect nursing diagnosis is impossible to write, so that is not an issue. Having standardized nursing diagnoses recognized in state practice acts or by other professions has nothing to do with the value of the NANDA-I taxonomy. PTS:1DIFgrinifficultREF: p. 57 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall

The patient verbalizes an overwhelming lack of energy. He says, "I still feel exhausted even after I sleep. I feel guilty when I can't keep up with my usual daily activities or sleep during the day. I've been a little depressed lately, too." The patient seems to have difficulty concentrating but has no apparent physical problems. Which of the following diagnoses best describes his health status? 1) Fatigue related to depression 2) Fatigue related to difficulty concentrating 3) Guilt related to lack of energy 4) Chronic confusion related to lack of energy

ANS: 1 The diagnosis that best describes the overall health status is Fatigue. The only cue that might cause Fatigue is depression. You cannot use depression as the problem because it is a medical diagnosis, and it is not a NANDA-I label. The other cues (difficulty concentrating, inability to perform ADLs, and guilt) are symptoms of Fatigue, not etiologies. These diagnoses would lead the nurse to focus on dealing with guilt and confusion, so the source of the Fatigue would not be addressed. PTS: 1 DIF: Difficult REF: pp. 70-73 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application

Which of the following nursing diagnoses is written in correct format? Assume the facts are correct in all of them. 1) Readiness for Enhanced Nutrition 2) Pain related to stating, "On a scale of 1 to 5, it's a 5." 3) Impaired Mobility related to pain A.M.B. hip fracture 4) Risk for Infection related to compromised immunity A.M.B. fever

ANS: 1 Wellness diagnoses (e.g., Readiness for Enhanced . . .) are usually one-part statements. A pain ranking of 5 is a symptom of pain, not an etiology, so it should be preceded by "A.M.B." or "as manifested by." Hip fracture is a medical diagnosis that is causing an etiology of pain; therefore, it should be preceded by "secondary to." Risk diagnoses do not have symptoms, so it is not correct to put anything after "A.M.B." PTS: 1 DIF: Moderate REF: pp. 70-73 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application

Which of the following is an example of a problem that nurses can treat independently? 1) Hemorrhage 2) Nausea 3) Fracture 4) Infection

ANS: 2 A nursing diagnosis (or nursing problem) is a human response to a disease, injury, or other stressor that nurses can identify, prevent, or treat independently. Nausea is the only problem that meets that criterion; all others are medical or collaborative problems. PTS:1DIF:ModerateREF: pp. 57 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application

How does a risk nursing diagnosis differ from a possible nursing diagnosis? 1) A risk diagnosis is based on data about the patient. 2) A possible diagnosis is based on partial (or incomplete) data. 3) Nurses collect the data to support risk diagnoses. 4) A possible diagnosis becomes an actual diagnosis when symptoms develop.

ANS: 2 A possible nursing diagnosis is based on nursing knowledge, intuition, and experience and does not have enough data to support it; it is based on incomplete data. A risk diagnosis describes a problem that may develop in a vulnerable client if nursing care is not initiated to prevent it; it is made when risk factors are present in the data. Nurses collect data to support both risk and possible diagnoses; therefore, this statement does not differentiate them. A risk diagnosis becomes an actual diagnosis when symptoms develop. PTS:1DIF:ModerateREF:p. 60 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis

Based only on Maslow's hierarchy of needs, which nursing diagnosis should have the highest priority? 1) Self-care Deficit 2) Risk for Aspiration 3) Impaired Physical Mobility 4) Disturbed Sensory Perception

ANS: 2 Highest priority is given to problems that are life threatening or that could be destructive to the client. Safety is most basic in Maslow's hierarchy. Even though Risk for Aspiration is not an actual problem, it poses the most immediate life-threatening risk to the client, and nursing interventions must be performed to prevent it from becoming an actual problem. PTS:1DIF:ModerateREF:pp. 64-65 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

What is wrong with the format of this diagnostic statement: Possible Risk for Constipation related to irregular defecation habits A.M.B. statement that "When I'm busy, I can't always take the time to go to the bathroom." 1) Possible nursing diagnoses do not have signs and symptoms. 2) A nursing diagnosis is either a possible risk or a risk, not both. 3) Constipation is a medical diagnosis. 4) The etiology is actually a defining characteristic.

ANS: 2 If there are risk factors, it is not a possible diagnosis, it is a risk diagnosis. It is possible to have a "possible risk for" diagnosis. The patient with possible diagnoses may have symptoms, just not enough to support the diagnosis. Constipation is a nursing diagnosis, and the etiology is a defining characteristic for a risk diagnosis because it contributes to the problem. In risk diagnoses, the etiology consists of the risk factors. PTS: 1 DIF: Moderate REF: pp. 60 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis

Which of the following are cues? Select all that apply. 1) Taking a brisk walk five times a week 2) Using laxatives to have a bowel movement 3) Needing more sleep than usual 4) Decreasing the amount of fat in the diet 5) Weighing less than indicated by developmental norms

ANS: 2, 3, 5 Cues are a deviation from norms, such as changes in usual health behavior, indications of delayed growth and development, changes in behaviors, or nonproductive or dysfunctional behavior. PTS:1DIF:ModerateREF:p. 61-62 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application

The patient shows the necessary defining characteristics, and the nurse has diagnosed Decisional Conflict related to unclear personal values and beliefs. What essential action should the nurse take to help ensure the accuracy of this diagnosis? 1) Ask a more experienced nurse to confirm it. 2) Have a social worker interview the patient. 3) Ask the patient to confirm the diagnosis. 4) Read about Decisional Conflict in the NANDA-I handbook.

ANS: 3 After identifying problems and etiologies (which this nurse has done), the nurse should verify them with the patient to help ensure that her conclusions are accurate. If the patient does not agree that he has Decisional Conflict, the nurse might interview him more to clarify the meaning of the data. Certainly the nurse could ask another nurse's opinion, but that is not essential. It would make no sense to have a social worker interview the patient unless the situation remains unclear even after confirming with the client. If the nurse did have adequate theoretical knowledge of Decisional Conflict for this patient, she should have been informed by reading the NANDA-I handbook before making the diagnosis. If the patient does not confirm the diagnosis, and the nurse concludes the diagnosis is in error, she might then reread the NANDA-I guide. PTS: 1 DIF: Moderate REF: V1, p. 56 | p. 63 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application

Which of the following is the best approach to validate a clinical inference? 1) Have another nurse evaluate it. 2) Have the physician evaluate it. 3) Have sufficient supportive data. 4) Have the client's family confirm it.

ANS: 3 All clinical inferences should be well supported by data. The more reliable data you gather, the more certain you can be that your inference is accurate. Because inferences are nursing diagnoses, it would be inappropriate to have a physician evaluate them. Although another experienced nurse could evaluate the inference, it still needs to be supported by sound and sufficient data. Even clients can validate clinical inferences in some situations, but adequate supporting data are still needed. Keep in mind that the client's data might or might not be sufficient to "prove" the inference. PTS: 1 DIF: Easy REF: p. 63 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall

Which of the following most accurately describes nursing diagnoses? A nursing diagnosis 1) Supports the nurse's diagnostic reasoning 2) Supports the client's medical diagnosis 3) Identifies a client's response to a health problem 4) Identifies a client's health problem

ANS: 3 Nursing diagnoses are statements that nurses use to describe a client's physical, mental, emotional, spiritual, and social response to disease, injury, or other stressor. Diagnostic reasoning is used to identify the appropriate nursing diagnosis; it is not meant to "support" the diagnosis. A health problem is a condition that requires intervention to promote wellness or prevent illness; it is sometimes, but not always, a nursing diagnosis. Nursing diagnoses are not medical diagnoses. PTS:1DIF:ModerateREF: p. 57 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis

Which nursing diagnosis is written in the correct format when using the NANDA-I taxonomy? 1) Bowel Obstruction related to recent abdominal surgery A.M.B. nausea, vomiting, and abdominal pain 2) Inability to Ingest Food related to imbalanced nutrition: less than body requirements A.M.B. inadequate food intake, weight less than 20% under ideal body weight 3) Impaired Skin Integrity related to physical immobility A.M.B. skin tear over sacral area 4) Caregiver Role Strain related to alienation from family and friends A.M.B 24-hour care responsibilities

ANS: 3 The components of NANDA-I nursing diagnosis might include the following four parts: diagnostic label, defining characteristics, related factors, and risk factors. "Impaired Skin Integrity . . ." has the problem statement, etiology, and symptoms. For "Bowel Obstruction . . ." the problem is a medical diagnosis. The cause-and-effect order of "Inability to Ingest Food . . ." is incorrect; it starts with the etiology. The etiology and symptoms (A.M.B.) of "Caregiver Role Strain . . ." are reversed (alienation from family and friends are the symptoms that support the diagnosis). PTS: 1 DIF: Difficult REF: pp. 70-71 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application

Which of the following explains why it is important to have the correct etiology for a nursing diagnosis? The etiology 1) Is the cause of the problem 2) Cannot always be observed 3) Directs nursing care 4) Is an inference

ANS: 3 The etiology directs nursing interventions. If the incorrect etiology is given, the nursing care would not be appropriate for the client. The other statements are true but not a reason for the importance of the etiology being correct. PTS:1DIFgrinifficultREF:pp. 63 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis

Which nursing diagnosis is written in the correct format? 1) Imbalanced Nutrition: Less than Body Requirements related to body weight less than 20% under ideal weight 2) Ineffective Airway Clearance related to increased respiratory rate and irregular rhythm 3) Impaired Swallowing related to absent gag reflex 4) Excess Fluid Volume related to 3 lb weight gain in 24 hours

ANS: 3 The etiology should describe what is causing or contributing to the problem. The etiologies for Ineffective Airway Clearance, Impaired Airway Swallowing, and Excess Fluid Volume describe signs or symptoms rather than causal factors. PTS: 1 DIF: Difficult REF: V1, p. 64 | pp. 70-73 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis

Which of the following describes the most important use of nursing diagnosis? (All statements are true.) 1) Differentiates the nurse's role from that of the physician 2) Identifies a body of knowledge unique to nursing 3) Helps nursing develop a more professional image 4) Describes the client's needs for nursing care

ANS: 4 Benefits to nurses and nursing are that nursing diagnoses differentiate the nurse's role, they identify a unique body of nursing knowledge, and some think they help nursing to develop a more professional image. However, the primary goal of nursing is to serve the good of the patient. Therefore, the most important use of a diagnosis is to specifically identify the client's needs for quality nursing care. PTS: 1 DIF: Moderate REF: p. 56 KEY: Nursing process: Diagnosis | Client need: Safe-care environment | Cognitive level: Analysis

Which of the following describes the difference between a collaborative problem and a medical diagnosis? 1) A collaborative problem is treated by the nurse; a physician is responsible for the treatment of a medical problem. 2) A collaborative problem is a nursing diagnosis that requires specific orders from a physician; a medical diagnosis directs all nursing care. 3) A collaborative problem has the potential to become an actual nursing diagnosis; a medical diagnosis rarely changes. 4) A collaborative problem requires intervention by the nurse and physician or other professional; a medical diagnosis requires intervention by a physician.

ANS: 4 Collaborative problems are physiological complications a client may be at risk for due to her medical diagnosis, medical treatment, or diagnostic studies. A collaborative problem requires monitoring by the nurse and intervention by a physician. A medical diagnosis requires interventions (medications, treatments) by the physician. Medical diagnoses do not direct all nursing care. Collaborative problems have the potential to become medical, not nursing, diagnoses. PTS:1DIF:ModerateREF: pp. 58-59 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis

When making a diagnosis using NANDA-I, which of the following provides support for the diagnostic label you choose? 1) Etiology 2) Related factors 3) Diagnostic label 4) Defining characteristics

ANS: 4 The defining characteristics are the signs and symptoms that must be present to support any given nursing diagnosis. The etiology and related factors are the causes or contributing factors to the problem. The diagnostic label is the name NANDA-I has given the problem; it is chosen based on the presence of defining characteristics. PTS:1DIF:EasyREF:p. 68 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall

The client's weight is appropriate for his height. His laboratory values and other assessments reflect normal nutritional status. However, he has told the nurse, "I probably eat a little too much red meat. And what is this I hear about needing omega 3 oils in my diet? I don't like to take supplements, and I think I could really improve my nutrition." Which of the following nursing diagnoses should the nurse use? 1) Balanced Nutrition 2) Possible Imbalanced Nutrition: Less Than Body Requirements 3) Risk for Imbalanced Nutrition: Less Than Body Requirements 4) Readiness for Enhanced Nutrition

ANS: 4 You will use a wellness diagnosis when a person's present level of wellness is effective and when the person wants to move to a higher level of wellness—in this case, a higher level of nutrition. The format for a wellness diagnosis is "Readiness for Enhanced . . ." Use a possible diagnosis when you have enough data to suspect a problem but need more data to support a diagnosis. Use a risk diagnosis when there are risk factors for a problem. PTS: 1 DIF: Moderate REF: p. 72 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application

Using Maslow's hierarchy of needs, rank the following nursing diagnoses in order of importance, beginning with the highest-priority diagnosis. 1) Anxiety 2) Risk for infection 3) Disturbed body image 4) Sleep deprivation

ANS: 4, 2, 1, 3 In Maslow's hierarchy, physiologic needs and safety are the highest priority. Sleep is a basic physiologic need. Infection can threaten physical health. In this question, infection is not present; therefore, there is just a risk for it. Sleep Deprivation is an immediate problem that affects general physical, mental, and emotional health. Neither Anxiety nor Disturbed Body image is a physiologic or safety need. Anxiety is a more immediate need than Disturbed Body Image, so it probably deserves a higher ranking. Remind students that the ranking would depend on the severity of each problem, which is not known by the labels alone. PTS:1DIFgrinifficultREF:pp. 64 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis