FN - Chapter 16: Diagnosis/Problem Identification

Which information ensures accuracy when the nurse is developing a nursing diagnosis? A set of lab values Abnormal diagnostic test results A cluster of clinical cues Specific nursing interventions

A cluster of clinical cues Each piece of client information is considered a clinical cue; a set of clinical cues that all suggest the same problem form a cue cluster. Basing a nursing diagnosis on a cluster of cues rather than a single cue improves the accuracy of the nursing diagnosis. Lab values or abnormal diagnostic test results along would not be as likely to improve accuracy as a cluster of related cues. The nurse would develop specific nursing interventions during the planning phase of the nursing process, immediately after the diagnosing phase.

A 19-year-old college basketball player is being evaluated for injuries after a skiing accident. The nurse determines that the client has a pulse of 52 beats/min. What would be the most appropriate way for the nurse to determine the significance of the client's heart rate? Ask the client whether the heart rate is normal for the client. Compare the client's heart rate to that another adolescent client. Have another nurse reassess the heart rate for accuracy. Determine whether the client has any risk factors for cardiac disease.

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

Which type of health problem requires both health care provider- and nurse-prescribed actions to address? Independent health problem Collaborative health problem Health care provider-developed problem Interdisciplinary health problem

Collaborative health problem If a problem requires both health care provider- 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.

A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify? Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor Homelessness Syndrome related to lack of housing as evidenced by visibly soiled clothing Inadequate Hygiene related to homelessness as evidenced by client's stink Impaired Impulse Control related to poor socioeconomic conditions as evidenced by visibly soiled clothing

Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor The most appropriate diagnosis would be "Bathing Self-care Deficit. The client is homeless and would not be able to access bathroom facilities. Homelessness has not been identified as a syndrome and there is only evidence of one problem. Inadequate hygiene has not been identified as a nursing diagnosis; furthermore, the word "stink" is an offensive term that must be avoided in nursing documentation. There is no evidence to suggest that the client has any issues with impulse control.

A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination? Bowel Incontinence Ulcerative Colitis Irritable Bowel Syndrome Small Bowel Obstruction

Bowel Incontinence Bowel incontinence is a NANDA-I-approved nursing diagnosis under the domain of Elimination. Ulcerative colitis, irritable bowel syndrome, and small bowel obstruction are medical diagnoses.

What are nursing diagnoses based on? Symptoms Signs Cues Problems

Cues Nursing diagnoses are based on clusters of significant and related cues, or subjective (i.e., symptoms) and objective (i.e., signs) data that the nurse gathers during assessment. Problems are what nursing diagnoses describe, not what they are based on.

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 Disturbed Body Image Impaired Comfort Risk for Suicide

Risk for Powerlessness 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.

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 assess the client's dietary habits. The nurse should assess the client's bowel sounds. The nurse should determine the client's normal bowel elimination pattern. The nurse should determine the standard bowel elimination pattern for the client's age.

The nurse should determine the client's normal bowel elimination pattern. 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.

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 parent reports that the infant cries much of the night but sleeps better in the daytime. The parent reports that the child only breastfeeds about four times in a 24-hour period and that the parent does not seem to have much milk. Which nursing concern is the priority for this parent-infant dyad? altered breastfeeding altered sleep pattern altered comfort altered parenting risk

altered breastfeeding The frequency of breastfeeding is the likely cause of the infant's inability to gain weight. Feeding should be priority for a 3-week-old infant. Although the infant demonstrates an altered sleep pattern and altered comfort, these are not as important as the infant's inability to gain weight. There is no evidence that the parent is at risk for altered parenting.

The nursing diagnosis taxonomy provides nursing with: legal information. common language. discharge planning. evaluative care.

common language. A taxonomy, or classification system, provides nurses with a common language with which categorize client problems. Taxonomy applies primarily to nursing diagnoses and thus the diagnosing phase of the nursing process. It does not apply to legal information, discharge planning, or evaluative care.

When writing an actual nursing diagnosis, the nurse includes the etiology that contributes to the current situation. This would be identified as: diagnostic label. related factors. defining characteristics. problem statement.

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

A nurse is caring for a client who has pneumonia. What is an appropriate nursing diagnosis? Impaired Respiration Ineffective Airway Clearance Altered Airway Infection (Pulmonary)

Ineffective Airway Clearance Ineffective Airway Clearance is a plausible nursing diagnosis for a client with pneumonia. The other listed options are not recognized NANDA nursing diagnoses.

x A staff nurse comments to the charge nurse that it is unnecessary to know how to formulate nursing diagnoses because the computerized documentation system generates them automatically. What is the most appropriate response by the charge nurse? "A nurse is still responsible for using critical thinking to determine the validity of the nursing diagnoses generated." "Computerized documentation systems have eliminated the need for nurses to worry about nursing diagnoses." "Using computerized documentation systems allows for the standardization of client care." "The use of nursing diagnoses generated by a computerized documentation system is not responsible nursing practice."

"A nurse is still responsible for using critical thinking to determine the validity of the nursing diagnoses generated." Although computerized documentation systems may select nursing diagnoses, the nurse is still responsible for applying the diagnoses using critical thinking to clients. The computer system is intended as an aid, not to replace the nurse. Although computerized documentation systems allow for standardization of client care, this is not the most appropriate response by the charge nurse, as it does not address the staff nurse's erroneous comment that nurses do not need to know how to formulate nursing diagnoses. It is not true that use of nursing diagnoses generated by a computerized documentation system is irresponsible nursing practice, as long as the nurse verifies that the diagnoses are accurate.

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." "I feel great but wish that I could get more sleep." "My mother-in-law and I go for a walk daily." "My mother-in-law makes dinner on Tuesdays, and I cannot stand her cooking."

"I just don't have time to take a shower." 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 68-year-old client who had total hip replacement surgery 6 hours ago and is reporting moderate discomfort at the surgical site. A 32-year-old client with a urinary tract infection who is receiving an intravenous antibiotic and reporting swelling in the tongue. An 82-year-old client with emphysema who is receiving 2 liters of oxygen and is concerned about a pulse oximetry reading of 91%. A 48-year-old client with a hemoglobin of 9.5 g/dl (95 g/l) who is receiving ferrous sulfate supplements and is reporting feeling tired.

A 32-year-old client with a urinary tract infection who is receiving an intravenous antibiotic and reporting swelling in the tongue. 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 client who recently became quadriplegic as the result of a motor vehicle accident is experiencing multiple physical and emotional problems. To guide the care planning for this client, what type of nursing diagnosis would be most appropriate for the nurse to select? A problem-focused nursing diagnosis A possible nursing diagnosis A risk nursing diagnosis A syndrome nursing diagnosis

A syndrome nursing diagnosis Because the client is experiencing multiple problems beyond the scope of a single nursing diagnosis, a syndrome diagnosis is indicated. A problem-focused diagnosis, which addresses only one problem, is not sufficient. The client has identified actual problems, so a possible or risk 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 Nutritional-metabolic Coping-stress tolerance Cognitive-perceptual

Activity-exercise 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.

"Acute Pain related to instillation of peritoneal dialysate as evidenced by client wincing and grimacing during procedure, client description of experience as 'stabbing'" is an example of which type of nursing diagnosis? Actual nursing diagnosis Risk nursing diagnosis Health promotion nursing diagnosis Potential nursing diagnosis

Actual nursing diagnosis This is an actual nursing diagnosis as it contains the diagnostic label (acute pain), related factors (instillation of peritoneal dialysate), and defining characteristics (wincing, grimacing during procedure, stabbing sensation). A risk nursing diagnosis is a two-part statement that includes a diagnostic label and risk factors. A health promotion nursing diagnosis is one-part statement that includes a diagnostic label. A potential nursing diagnosis is a two-part statement that includes a diagnostic label and unknown related factors.

The nurse is caring for a client who underwent abdominal surgery today. Which nursing diagnoses would be appropriate for the nurse to identify for this client? Select all that apply. Acute Pain related to disruption of skin tissues secondary to abdominal surgery Risk for Infection related to altered tissue integrity Potential for Atelectasis related to decreased respirations Impaired Mobility related to fear of pain Risk for Constipation related to immobility

Acute Pain related to disruption of skin tissues secondary to abdominal surgery Risk for Infection related to altered tissue integrity Impaired Mobility related to fear of pain Risk for Constipation related to immobility All answers are appropriate, except for the potential for atelectasis. Because this is a potential complication of surgery, it requires a collaborative approach. The other diagnoses are within the scope of practice of nursing.

While caring for a client admitted to the hospital for a fractured tibia, the nurse notes the client's blood pressure readings are consistently higher the expected range for the client's age. How would the nurse most appropriately plan to care for this client? Address the collaborative problem PC: Hypertension. Address the nursing diagnosis, "Risk for Injury related to hypertension." Address the possible nursing diagnosis, "Ineffective Tissue Perfusion related to hypertension." Address the medical diagnosis of Hypertensive disorder.

Address the collaborative problem PC: Hypertension. Caring for the client with high blood pressure will require the services of several health care disciplines, including nursing, medicine, and nutrition. This will require a collaborative diagnosis. The nursing diagnosis of "Risk for Injury" does not address the need for multidisciplinary care. The client has an actual problem, not a possible problem, and the etiology is a medical diagnosis. Only addressing the medical interventions for hypertension is not comprehensive care for this client.

A nurse is applying the nursing process and is in the diagnosis phase. With which activities would the nurse be involved? Select all that apply. Collecting subjective and objective data Organizing data Analyzing data Identifying patterns Identifying indicators of potential dysfunction

Analyzing data Identifying patterns Identifying indicators of potential dysfunction During the diagnosis phase, the nurse analyzes collected data; identifies client strengths; identifies the client's normal functional level and indicators of actual or potential dysfunction; identifies patterns; validates the diagnosis; and formulates a diagnostic statement in relation to this synthesis. Collecting and organizing data are assessment activities.

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 severity of the client's illness. Assess the client's knowledge of COPD. Assess the client's financial resources. Assess the client's access to health care.

Assess the client's knowledge of COPD. 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? Another staff nurse Client's health care provider Client The unit's nurse manager

Client 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 Formulating a nursing diagnosis Validating the nursing diagnosis Identifying contributing factors

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

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. Establish short- and long-term client goals. Perform a focused assessment related to the reason for admission. Verify the primary care provider's written orders.

Collect client subjective and objective data. Nursing diagnoses are developed as the second step of the nursing process. The first step is to collect all assessment data so that appropriate actual or potential nursing problems can be selected and addressed in the client's plan of care. Nursing diagnoses are not related to the medical diagnosis or the specific written orders from the primary care provider. Goals can only be established after the problem is identified. 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 with congestive heart failure has dyspnea while ambulating to the bathroom. The nurse selects the nursing diagnosis of "Activity Intolerance" to address this health problem. Which etiology would be appropriate to select for this nursing diagnosis? Compromised oxygen transport Inadequate motivation Cardiac disease Fluid overload

Compromised oxygen transport The pathophysiology of congestive heart failure decreases the body's ability to transport oxygen through the body. There is no evidence of the client's unwillingness to ambulate. Cardiac disease is a medical diagnosis. Fluid overload is not necessarily the rationale for the activity intolerance, because it is the heart's failure to pump effectively that reduces the ability to transport oxygen to the organs.

Which example of client care is not the responsibility of the nurse? Monitoring for changes in health status Promoting safety and preventing harm; detecting and controlling risks Tailoring treatment and medication regimens for each individual Confirming a medical diagnosis

Confirming a medical diagnosis The nursing scope of practice dictates what is allowed and not allowed when providing nursing care. Confirming a medical diagnosis is not in the scope of nursing practice. Monitoring for changes in a client's health status, promoting safety and preventing harm, and tailoring treatment and medication regimens to the client's schedule of activities are all nursing care responsibilities.

Which is an example of a nursing diagnosis? Constipation Hypoglycemia Dehydration Depression

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

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 Readiness for Enhanced Nutrition related to constipation Bowel incontinence related to depressive state Diarrhea related to client report of small, loose stools

Constipation related to irregular evacuation patterns 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. Continue to collect assessment data. Document the data for future reference. Contact the client's health care provider.

Consult with a more experienced nurse. 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.

The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this infant, but I have always believed that abortion is a sin. I don't know what to do." What nursing diagnosis would be most appropriate for the nurse to formulate? Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement Hopelessness related to inability to decide a course of action as evidenced by the client's statement Complicated Grieving related to mental trauma as evidenced by the client's inability to make a decision Ineffective Coping related to rape trauma syndrome as evidenced by client's inability to make a decision

Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement The client's statement indicates that it is difficult for the client to reach a decision because of the client's moral beliefs. The client is not expressing hopelessness or demonstrating ineffective coping or complicated grieving. The client may be suffering from rape trauma syndrome, but the assessment data do not lead to that diagnosis.

The nurse formulates the following nursing diagnosis: Disturbed Body Image related to decreased ability to cope with surgical removal of right breast as evidenced by the client refusing to look at the surgical site and stating, "I'm ugly. My husband will no longer find me desirable." What is the etiology identified in this nursing diagnosis? Decreased ability to cope with surgical removal of right breast "I'm ugly. My husband will no longer find me desirable." Disturbed body image Refusal of the client to look at the surgical site

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

A 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? Alzheimer's disease Decreased level of consciousness Choking episode Fluids entering the client's airway

Decreased level of consciousness 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 nurse is caring for a client admitted with dehydration after completing a triathlon in a hot, dry climate. The nurse identifies an appropriate nursing diagnosis for this client as "Deficient Fluid Volume related to insufficient fluid intake as evidenced by blood pressure of 84/46 mm Hg, heart rate of 145 beats/min, concentrated urine, and client reporting drinking 200 mL of water during the 4-hour event." Which is the problem statement in this nursing diagnosis? Deficient fluid volume Insufficient fluid intake Blood pressure of 84/46 mm Hg, heart rate of 145 beats/min, concentrated urine Hot, dry climate

Deficient fluid volume The problem statement is "Deficient Fluid Volume." "Insufficient fluid intake" is the etiology in this nursing diagnosis. Defining characteristics include "blood pressure of 84/46 mm Hg, heart rate of 145 beats/min, concentrated urine, and client reporting drinking 200 mL of water during the 4-hour event." The phrase "hot, dry climate" is not a component of this nursing diagnosis statement.

Which describes the best approach for the development of nursing diagnoses? Develop nursing diagnoses from clusters of significant data. Develop each nursing diagnosis based on a single cue. Collaborate with the multidisciplinary team in the formation of nursing diagnoses. Collaborate with the health care provider in the formation of nursing diagnoses.

Develop nursing diagnoses from clusters of significant data. 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 health care providers or other health care team members.

The nurse is systematically gathering and clustering data to draw inferences regarding a newly admitted client's health problems. This process is best identified as which? Evaluation Critical thinking Diagnostic reasoning Intuition

Diagnostic reasoning Diagnostic reasoning is the process of gathering and clustering data to draw inferences regarding clients' health problems and to propose diagnoses. Evaluation is the final phase of the nursing process, in which the nurse assesses the effectiveness of interventions in meeting planned client outcomes. Critical thinking is a broad term that refers to thinking in which one examines assumptions, evaluates evidence, and uncovers underlying values and reasons. Although critical thinking is involved in diagnostic reasoning, the latter is a more specific and accurate term for systematically gathering and clustering data to develop diagnoses.

While caring for a client admitted with a Clostridium difficile infection, the nurse notes that the client has had three loose bowel movements in 3 hours. What would be the most appropriate nursing diagnosis to address this health problem? Diarrhea related to infectious process as evidenced by three loose bowel movements in 3 hours Risk for Infection Transmission related to high potential for communicability Fluid Volume Excess related to diarrhea as evidenced by three loose bowel movements in 3 hours Risk for Injury related to urgent need for bowel evacuation

Diarrhea related to infectious process as evidenced by three loose bowel movements in 3 hours The assessment data point to the diagnosis of diarrhea. The other three diagnoses may be part of the care plan for C. difficile, but the assessment data do not provide evidence for the other diagnoses. The client would be at greater risk for a fluid volume deficit rather than a fluid volume excess.

The nurse is assessing a client who was just admitted to the unit following an abdominal hysterectomy. On which assessment finding would the nurse base the priority diagnosis? Dressing intact with slight bloody discharge present Client reports being very sleepy Abdominal area soft with diminished bowel sounds throughout Diminished breath sounds in left lower lobe Skin warm and dry

Diminished breath sounds in left lower lobe Abnormal respiratory findings are a priority in the postoperative client. Slight discharge on the abdominal dressing may be expected but should be noted and observed for further bleeding. Being sleepy following anesthesia is a normal finding. Warm and dry skin is a normal finding.

After a client has a myocardial infarction, the nurse formulates a possible nursing diagnosis of "Powerlessness." To determine the accuracy of the diagnosis, what would be the nurse's most appropriate action? Determine the extent of cardiac tissue damage. Discuss the client's health condition with the client. Assess the client's knowledge of risk factors. Identify the client's support systems.

Discuss the client's health condition with the client. To validate the nursing diagnosis, the nurse must ascertain the client's feelings about the myocardial infarction. The most appropriate method is to talk to the client. Determining the amount of cardiac damage will not address the client's feelings. The client's knowledge of risk factors does not contribute to the validation of the nursing diagnosis. The client's support systems may assist the client to cope, but identifying them will not lead to any new information about the client's perceptions.

A nurse is providing care to several clients who have undergone surgery. When reviewing their electronic health records, which information would the nurse identify as reflecting a nursing diagnosis? Select all that apply. Disturbed Body Image Pain Impaired Skin Integrity Wound Infection Paralytic Ileus

Disturbed Body Image Pain Impaired Skin Integrity Disturbed Body Image, Pain, and Impaired Skin Integrity reflect nursing diagnoses, which are written to describe client problems or issues that nurses can treat independently. Wound Infection and Paralytic Ileus are medical diagnoses or collaborative problems involving potential complications.

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 breast cancer Disturbed Body Image related to loss of hair Disturbed Body Image as evidenced by client's refusal to look at self Disturbed Body Image as evidenced by client's negative comments

Disturbed Body Image related to loss of hair 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 nurse is developing a plan of care for a client with heart failure brought to the emergency department. The client was experiencing shortness of breath and pitting edema of the lower extremities. Which statement would the nurse identify as a the problem to be addressed in the client's nursing diagnosis? Excess Fluid Volume Heart Failure Shortness of Breath Edema

Excess Fluid Volume Nursing diagnoses are written to describe client problems or issues that nurses can treat independently, such as activity, pain and comfort, and tissue integrity and perfusion problems. The statement of excess fluid volume reflects a client problem. Heart failure is a medical diagnosis. Shortness of breath and edema are cues that support the nursing diagnosis of excess fluid volume.

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 Hypertension Congestive Heart Failure

Excess Fluid Volume Decreased Cardiac Output Activity Intolerance 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.

The nurse is planning care for a client who has experienced a myocardial infarction. Which would likely be appropriate nursing diagnoses for the nurse to select for this client? Select all that apply. Fear related to change in health status Pain related to cardiac tissue damage Abnormal Cardiac Rhythm Pulmonary Edema Determine Cardiac Function

Fear related to change in health status Pain related to cardiac tissue damage Fear and pain are appropriate nursing diagnoses, because they can be addressed by nursing care. Abnormal cardiac rhythm is an etiology for myocardial infarction. Pulmonary edema is a medical diagnosis. Determining cardiac function is the health care provider's domain.

A client who is scheduled for coronary angioplasty is concerned about whether the surgery is safe and wonders whether it would be beneficial. Which nursing diagnosis relates to this client's condition? Ineffective Coping related to anxiety and fear of surgery Anxiety related to fear of death during surgery Fear related to potential risk and surgical outcomes Knowledge Deficit: treatment regimen related to surgical outcomes

Fear related to potential risk and surgical outcomes The client expresses fear of the risks related to unknown outcome of surgery. The appropriate nursing diagnosis is Fear related to potential risk and surgical outcomes. Fear is always related to a known source; in this case it is the surgery. Anxiety is always related to unknown sources and is not applicable in this case. Coping and knowledge deficit are not related to fear of surgery.

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? Fluid volume deficit Gastrointestinal upset from food poisoning Slow skin turgor Vomiting

Gastrointestinal upset from food poisoning 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.

The nurse is caring for a client who has been diagnosed with a sexually transmitted infection (STI) for the fourth time in 4 years. The nurse plans to address the potential concern for the client's risk-prone behavior. What assumption prompted the nurse to address this concern? Having multiple STIs over multiple years means the client is sexually active. The client needs education to decrease the likelihood of repeated infection. Having an STI means the client is unaware of the risks of unprotected sex. The client does not understand the complications of STIs.

Having multiple STIs over multiple years means the client is sexually active. Risk-prone health behavior identifies habits of the client that are dangerous. Being sexually active places a client at higher risk. Risk-prone health behavior does not mean that the client does not understand how to prevent repeated infection, the risks of unprotected sex, or the complications of STIs. Therefore, there is no evidence that the nurse has made any of these assumptions.

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 abusive parents High Risk for Injury related to impaired home management Child Abuse related to unsafe home environment High Risk for Injury related to unsafe home environment

High Risk for Injury related to unsafe home environment 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 Disturbed Self-Concept related to pancreatic cancer diagnosis Ineffective Health Maintenance related to being overwhelmed by cancer diagnosis Knowledge Deficit: Cancer treatment options related to new diagnosis

Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis The client is expressing a lack of hope for the future, which makes "Hopelessness" an appropriate nursing diagnosis. There is no evidence that the client has a disturbed self-concept. There is no evidence that the client is not effectively caring for health. The client does not verbalize a desire to learn about treatment options.

When developing nursing diagnoses, the nurse should focus on which area? Actions to be initiated for treatment Human responses to actual or potential health problems Pathophysiological responses occurring in body systems Problem validation through health care provider collaboration

Human responses to actual or potential health problems 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 health care provider to validate the problem reflects medical diagnoses or collaborative problems.

A nurse is caring for a marathon runner who collapsed while running in extremely warm weather. Upon admission, the client's temperature is 102°F (38.9°C). What is the most appropriate nursing diagnosis? Dehydration Hyperthermia Heat Exhaustion Electrolyte Imbalance

Hyperthermia Physical exertion during extremely warm weather can lead to various health problems. The client was admitted with a temperature of 102°F (38.9°C) evidencing Hyperthermia. Dehydration is the probable cause or etiology of the Hyperthermia. Heat Exhaustion is a lay term. Electrolyte Imbalance is a collaborative problem that requires health care provider's orders to treat.

Which best describes the purpose of nursing diagnoses? Identification of client problems that nurses can treat independently Identification of signs and symptoms that identify diseases Identification of client problems that require collaboration with other health care professionals to treat Identification of actual client problems, not including potential problems

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

The client is admitted to the surgical unit following an exploratory laparotomy. Which nursing diagnosis is the priority? Deficient knowledge Impaired skin integrity Risk for imbalanced body temperature Fear/anxiety

Impaired skin integrity The priority nursing diagnosis is impaired skin integrity. The skin is the body's first line of defense against infection and the surgical incision impairs skin integrity, increasing the risk for infection. Deficient knowledge requires teaching, and during the early postoperative period, most clients will not be in a condition to accept teaching. Actual diagnoses are a priority over "risk for" diagnoses. Fear and anxiety cannot be addressed until basic physiologic needs are met.

Which activities does the nurse perform during the diagnosing stage? Select all that apply. Establish plan priorities with the client and family. Identify factors contributing to the client's health problem. Prioritize the client's health problems with input from the client. Validate the identified health problems with the clients. Collect data to monitor quality and effectiveness of nursing practice.

Identify factors contributing to the client's health problem. Prioritize the client's health problems with input from the client. Validate the identified health problems with the clients. During the diagnosis stage, the nurse identifies factors contributing to the client's health problem, validates the identified health problems with the client, and prioritizes the client's health problems with input from the client. The nurse establishes plan priorities with the client and family during the outcome identification and planning. The nurse collects data to monitor the quality and effectiveness of nursing practice during the evaluation stage.

When developing a nursing diagnosis for a client, which should the nurse do first? Identify the significant data Cluster the cues Synthesize cue clusters Validate the diagnosis

Identify the significant data 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.

Which would be an appropriate nursing diagnosis for a client with cachexia and decreased weight? Anorexia Nervosa Lack of Adequate Nutrition Weight Loss Imbalanced Nutrition: Less than Body Requirements

Imbalanced Nutrition: Less than Body Requirements 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.

The nurse formulates for a client the nursing diagnosis of: Impaired Physical Mobility related to postoperative pain as evidenced by difficulty ambulating. Which component of this nursing diagnosis is the descriptor? Impaired Physical mobility Postoperative pain Difficulty ambulating

Impaired Descriptors are words used to give additional meaning to a nursing diagnosis. They describe the change in condition, state of the client, or some qualification of the specific nursing diagnosis. In this example, the word "impaired" is a descriptor. Physical mobility is the diagnostic label. Postoperative pain is the related factor or etiology contributing to the problem. Difficulty ambulating is the defining characteristic, or the cue that supports the existence of the problem.

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 Disturbed Body Image Disturbed Sleep Pattern Activity Intolerance

Impaired Comfort 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.

While planning care for a client immediately after surgery, the nurse formulates a nursing diagnosis of "Risk for Injury." Which assessment data would be appropriate for the nurse to identify as possible etiologies for the diagnosis? Select all that apply. Visual deficit Effects of pain medications Impaired mobility Unfamiliarity with the hospital environment Two side rails up at all times

Impaired mobility Unfamiliarity with the hospital environment Potential hazards that would indicate a "Risk for Injury" include anything that hinders the client's ability to self-protect. Visual deficits, the disorienting effects of pain medications, deficits in mobility, and being unfamiliar with the environment all increase the safety hazards of the client. Two side rails up at all times is a possible nursing intervention used to help protect the client.

Which assessment findings would support the nursing diagnosis of Impaired Skin Integrity? Select all that apply. Impaired mobility due to recent stroke Unable to turn in bed without assistance Uncontrolled diabetes History of appendectomy Up with assistance to bedside commode

Impaired mobility due to recent stroke Unable to turn in bed without assistance Uncontrolled diabetes Diabetes, impaired mobility, and needing assistance to turn in bed increase the risk of skin breakdown. A past surgical history would not contribute to the diagnosis. Increasing mobility by moving the client to the bedside commode would lessen the chance for skin breakdown.

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 at 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. Risk for anxiety related to fear of ambulating postoperatively. Anxiety related to knowledge deficit regarding normal postoperative activities. Risk for postoperative complications due to disturbed body image.

Impaired physical mobility related to anxiety as evidenced by expressed fear of postoperative complications. 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? Bronchial Pneumonia Ineffective Airway Clearance Acute Dyspnea Asthma Attack

Ineffective Airway Clearance 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.

Which is the best example of a nursing diagnosis? Gastroesophageal Reflux related to low stomach pH as evidenced by foul breath and burning sensation in throat. Ineffective Airway Clearance as evidenced by client not speaking. Ineffective Breastfeeding related to latching as evidenced by nonsustained suckling at the breast. Cellulitis related to infection as evidenced by warm, reddened skin.

Ineffective Breastfeeding related to latching as evidenced by nonsustained suckling at the breast. 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.

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? Risk for Unstable Blood Glucose related to client's reluctance to manage the diabetic regimen Ineffective Health Maintenance related to client's denial of illness Risk for Injury related to client's mismanagement of disease Ineffective Coping related to client's inability to manage the diabetic regimen

Ineffective Health Maintenance related to client's denial of illness 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.

Nurses use approved NANDA-I nursing diagnoses when writing diagnoses for clients. Which diagnoses represent "Domain 1: Health Promotion" as established by NANDA-I? Select all that apply. Ineffective Health Management Risk for Disuse Syndrome Impaired Environmental Interpretation Syndrome Sedentary Lifestyle Decreased Diversional Activity Engagement Readiness for Enhanced Coping

Ineffective Health Management Sedentary Lifestyle Decreased Diversional Activity Engagement The definition of Domain 1 nursing diagnoses is: the awareness of well-being or normality of function and the strategies used to maintain control of and enhance that well-being or normality of function. Ineffective Health Management, Sedentary Lifestyle, and Decreased Diversional Activity Engagement are found in this category. Risk for Disuse Syndrome is found in Domain 4: Activity/Rest. Impaired Environmental Interpretation Syndrome is found in Domain 5: Perception/Cognition. Readiness for Enhanced Coping is found in Domain 9: Coping/Stress Tolerance.

A client is brought to the emergency room in respiratory arrest and is immediately intubated and placed on mechanical ventilation. What is the most appropriate nursing diagnosis for this client? Ineffective spontaneous ventilation Ineffective breathing pattern Ineffective airway clearance Impaired gas exchange

Ineffective spontaneous ventilation Ineffective spontaneous ventilation is the most appropriate nursing diagnosis for the client because the client unable to breathe as the result of respiratory failure. Ineffective breathing pattern is appropriate when the client can breathe on one's own but has difficulty breathing due to a high respiratory rate. Ineffective airway clearance is an inaccurate diagnosis here because the airways are clear and not blocked by secretions. Additionally, the diagnosis of impaired gas exchange is inappropriate because there is no known lung pathology or anemia.

An adolescent on life support after a diving accident has no brain wave activity. The parents tell the nurse they are sure their child will wake up soon. Which nursing diagnosis would the nurse identify to assist the parents of the child? Interrupted Family Processes related to inability to accept their child's inevitable death as evidenced by the parents' statement that their child will wake soon Interrupted Family Processes related to brain death of their child as evidenced by parents' refusal to accept the inevitable Death Anxiety related to anticipated death of child as evidenced by child having no brain wave activity Death Anxiety related to dysfunctional family processes as evidenced by parents' refusal to acknowledge the child's condition

Interrupted Family Processes related to inability to accept their child's inevitable death as evidenced by the parents' statement that their child will wake soon The parents of the adolescent verbalize a denial of their child's condition by their statement. They are unable to accept their child's death and the normal family processes of beginning that acceptance. Brain death of the child cannot be changed, so it is an unacceptable etiology. Death anxiety is an inappropriate nursing diagnosis because the diagnosis refers to anxiety over death of self.

The nurse is admitting a client who is unable to identify person, place, or time. To properly analyze these data, what action must the nurse take? Determine the client's medical diagnosis for clarification. Interview the client's family to assess the client's usual level of cognition. Assess the client's vital signs to determine the client's baseline. Ensure precautions are taken to prevent injury to the client.

Interview the client's family to assess the client's usual level of cognition. To properly analyze the assessment data, the nurse must compare them against the client's normal or baseline data. The family is the best informant for a client with cognitive impairment. The medical diagnosis is not necessary to determine whether the client's condition is abnormal for the client. The nurse should obtain the vital signs, but doing so will not give an indication of the client's usual level of cognition. Ensuring the client's safety is an important nursing intervention but will not assist in analyzing these data.

Which nursing diagnosis has the priority when caring for an older adult client with Alzheimer disease? Impaired Physical Mobility Risk for Injury Self-Care Deficit Impaired Memory

Risk for Injury Clients with Alzheimer disease are highly prone to injuries. Risk of Injury may also be precipitated by the altered memory. Mortality and morbidity resulting from injury is highest in older age groups. Consequently, it is very important for the nurse to provide a safe and secure environment. Impaired Physical Mobility, Self-Care Deficit, and Impaired Memory are also present but are not the highest priority.

A 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 Ineffective Airway Clearance related to bronchial constriction Noncompliance related to deficient knowledge of a new medical diagnosis Anticipatory Grieving related to chronic illness management

Knowledge Deficit: Medications related to new medical diagnosis To most appropriately address the client's health problem, the nurse should educate the client about the new medications the health care provider 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.

Which are accurate guidelines when formulating nursing diagnoses? Select all that apply. Include the medical diagnosis in the nursing diagnosis. Make sure the client problem precedes the etiology. Write the diagnosis in legally advisable terms. Phrase the nursing diagnosis as a client need rather than an alteration. Be sure the problem statement indicates what is unhealthy about the client. Make sure defining characteristics follow the etiology.

Make sure the client problem precedes the etiology. Write the diagnosis in legally advisable terms. Be sure the problem statement indicates what is unhealthy about the client. Make sure defining characteristics follow the etiology. The etiology is the cause of the client problem; therefore, the nursing diagnosis precedes the etiology. The nurse should write the nursing diagnosis in legally advisable terms. The problem statement, which is the nursing diagnosis, indicates what is wrong with the client. Defining characteristics support the nursing diagnosis and should follow the etiology to show support for the nursing diagnosis. A medical diagnosis is only made by a primary care provider and should not be included in the nursing diagnosis because the nurse cannot prescribe treatment for a medical diagnosis. The nursing diagnosis is the identification of a client alteration or problem, not a need.

The formulation of nursing diagnoses is unique to the nursing profession. Which statement accurately represents a characteristic of diagnosing? Nursing diagnoses remain the same for as long as the disease is present. Nurses formulate nursing diagnoses to identify diseases. Nurses write nursing diagnoses to describe client problems that nurses can treat. Nursing diagnoses focus on identifying healthy responses to health and illness.

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

A nurse documents the following in the client chart: Risk for Decreased Cardiac Output related to myocardial ischemia. This is an example of what aspect of client care? Nursing diagnosis Nursing assessment Medical diagnosis Collaborative problem

Nursing diagnosis The nursing diagnosis statement is worded by stating the client problem (using NANDA-I approved diagnoses) that the nurse is able to treat followed by the etiology of the problem. Nursing assessment refers to the collection of data. A medical diagnosis identifies diseases, whereas nursing diagnoses focus on unhealthy responses to health and illness. Nurses cannot treat medical diagnoses independently. Collaborative problems are the primary responsibility of nurses. Unlike nursing diagnoses, with collaborative problems, the prescription for treatment comes from nursing, medicine, and other disciplines.

A client has been diagnosed with a recent myocardial infarction. What collaborative problem would be the priority for the nurse to address? PC: Decreased Cardiac Output related to cardiac tissue damage PC: Disturbed Body Image related to decreased activity tolerance PC: Activity Intolerance related to decreased oxygenation capacity PC: Fear related to new diagnosis of myocardial infarction

PC: Decreased Cardiac Output related to cardiac tissue damage All these collaborative problems may be indicated for a client with a recent myocardial infarction; however, priority must be given to life-threatening issues. Decreased cardiac output is the only life-threatening problem among the answer options, so it must be the priority.

A client with diabetes mellitus has been admitted to the intensive care unit with a serum glucose reading of 400 mg/dL (22.20 mmol/L). Because the care for this client will involve multiple disciplines, which diagnostic statement would be most appropriate for the nurse to select? Risk for Unstable Blood Glucose related to diabetes PC: Hyperglycemia related to uncontrolled serum glucose Diabetes Mellitus as evidenced by serum glucose of 400 mg/dL (22.20 mmol/L) Need for Glucose Control as evidenced by hyperglycemia

PC: Hyperglycemia related to uncontrolled serum glucose PC: Hyperglycemia is the only diagnostic statement that addresses the services of multiple disciplines. Risk for Unstable Blood Glucose relates to independent nursing interventions and the etiology is inappropriate. Diabetes Mellitus is a medical diagnosis. Need for Glucose Control is incorrectly phrased. It addresses a client need, rather than a nursing diagnosis.

A client whose care plan includes a nursing diagnosis of "Risk for Infection related to a disruption of skin integrity secondary to abdominal surgery" is displaying redness, edema, and warmth at the surgical site. What would be the nurse's most appropriate revision of the care plan? PC: Infection related to disrupted skin integrity secondary to abdominal surgery Risk for Infection related to a disruption of skin integrity secondary to abdominal surgery to be treated by an antibiotic Wound Infection related to infectious processes Infection as evidenced by redness, edema, and warmth at the surgical site

PC: Infection related to disrupted skin integrity secondary to abdominal surgery When the client is at risk for infection, nurses can care for the client with independent nursing interventions. Once the client becomes infected, the client will need an antibiotic, which the health care provider must prescribe and which necessitates a collaborative diagnosis. The nursing diagnosis never addresses prescribed medication. Nurses do not formulate medical diagnoses. Actual infection is no longer an independent nursing problem.

A nurse suspects that a client has a self-care deficit, but needs more data to confirm this diagnosis. What nursing diagnosis would the nurse write for this client? Actual Potential Possible Apparent

Possible Possible nursing diagnoses are statements describing a suspected problem for which additional data are needed. Additional data are used to confirm or rule out the suspected problem. An actual nursing diagnosis means that there is data to support a client's actual health care problem. NANDA-I describes five types of nursing diagnoses: actual, risk, possible, health promotion, and syndrome.

Which nursing diagnosis is written incorrectly as a result of the health problem and etiology being reversed? Pain related to tissue trauma and inflammation Risk for Injury related to lack of knowledge of crutch walking Risk for Disturbed Body Image related to decreased ability to cope with surgical removal of right breast Prolonged Immobility related to impaired skin integrity

Prolonged Immobility related to impaired skin integrity Impaired Skin Integrity related to prolonged immobility is the correct format. Prolonged immobility contributes (etiology) to impaired skin integrity (problem), but the impaired skin integrity does not contribute to prolonged immobility. The other nursing diagnoses are correct.

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 Ineffective Health Maintenance related to lack of knowledge of childhood immunizations Risk for Infection Transmission related to lack of immunizations Risk for Complications related to childhood illnesses

Readiness for Enhanced Knowledge: Childhood Immunizations 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.

An older adult client recently admitted to a long-term care facility expresses anger and depression about the relocation. The client consumes very little food and is losing weight. Which nursing diagnosis would be most appropriate for the nurse to select to plan this client's care? Relocation Stress Syndrome Imbalanced Nutrition: Less Than Body Requirements Ineffective Coping Impaired Social Interaction

Relocation Stress Syndrome Because the client has multiple health problems relating to the relocation to the long-term care facility, Relocation Stress Syndrome is the most effective way to address the client's health issues. The client does have imbalanced nutrition, ineffective coping, and impaired social interaction, but all of these issues are addressed by the syndrome diagnosis.

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 Independently managing the client's kidney failure Coordinating the treatment of the client's kidney failure Choosing interventions to resolve the client's kidney failure

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

Which action is a priority role of the nurse when caring for a client with collaborative problems? Assessing the client's understanding of risk factors Resolving health issues through independent nursing measures Reporting trends that suggest the development of complications Managing an emerging problem with the help of another registered nurse

Reporting trends that suggest the development of complications 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 health care provider-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.

Which error has the nurse made in formulating the following nursing diagnosis: Prolonged Immobility related to impaired skin integrity as evidenced by an open area with a 1-inch diameter on the right buttocks surrounded by a 1-inch margin of redness; wound surface clean and beefy red; no drainage or foul odor detected. Wrote the diagnosis in terms of a need rather than a client response Reversed the health problem and the etiology Omitted the defining characteristics of the client health problem Identified environmental factors rather than client factors as the problem

Reversed the health problem and the etiology The nurse has reversed the health problem and etiology. Impaired Skin Integrity related to prolonged immobility is the correct format. The nursing diagnosis does address a client response rather than need: impaired skin integrity as a response to prolonged immobility. The nursing diagnosis does include defining characteristics: open area on the buttocks, wound surface clean and beefy red, no drainage or foul odor. The nursing diagnosis does not refer to environmental factors.

After completing a client abdominal assessment, the nurse finds diminished bowel sounds. To determine what intervention is needed, which step would the nurse take first? Review the client's recent food and fluid intake. Prepare the client for administration of laxative medication. Provide teaching about the prevention of constipation. Encourage the client to drink more fluids and eat more fiber.

Review the client's recent food and fluid intake. The first step in interpreting and analyzing the data involves identifying cues or significant data that raise a red flag. From there, the nurse would look for patterns or clusters of data that signify an actual or possible nursing problem. Preparing the client for laxative administration indicates the nurse has skipped some necessary steps in the nursing process. The nurse must first engage in a process of analysis and interpretation of data prior to formulating a hypothesis about a potential or actual problem. Providing teaching about constipation and encouraging the client to change food and fluid intake assumes the nurse has proceeded logically through each step of the nursing process to develop the conclusion that diminished bowel sounds are the result of constipation. Further data needs to be collected, analyzed and interpreted before the nurse can plan and carry out this intervention.

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? Anxiety related to surgical procedure Knowledge Deficit related to surgical procedure Risk for Allergy Response related to latex allergy Risk for Injury related to latex allergy

Risk for Allergy Response related to latex allergy 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.

A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern? Knowledge Deficit related to effects of chemical plant pollution Deficient Community Health related to chemical plant Risk for Community Contamination related to possible environmental pollution Risk for Infection related to community contamination

Risk for Community Contamination related to possible environmental pollution The nurse has identified a risk diagnosis because of the unknown health effects of the chemical plant on the community. Risk for Community Contamination would address the broad concerns of the nurse. Knowledge Deficit is not appropriate because it has too narrow a focus. Deficient Community Health is not a NANDA-I diagnosis and the etiology must deal with how the plant may possibly affect the community. Risk for Infection has a very narrow focus. The etiology of community contamination has not been proven.

Which is an accurately phrased risk nursing diagnosis? Risk for Impaired Coping as evidenced by client crying Risk for Fluid Volume Excess related to increased oral intake as evidenced by consuming 3 L of soda Risk for Pain After Surgery Risk for Falls related to altered mobility

Risk for Falls related to altered mobility 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? Ineffective Airway Clearance related to bed rest Immobility related to confinement to bed Potential for Pneumonia related to inactivity Risk for Impaired Skin Integrity related to bed rest

Risk for Impaired Skin Integrity related to bed rest 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."

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 Acute Confusion related to appropriate wound care Knowledge Deficit due to risk for infection Risk for sepsis related to local infection.

Risk for Infection related to knowledge deficit 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.

Which assessment findings would support the nursing diagnosis of Acute Pain? Select all that apply. The client had an abdominal hysterectomy 1 day ago. The client is crying in pain about 20 minutes before pain medicine is due. The client has a history of osteoarthritis. The client had back surgery 2 years ago and expresses the need for ibuprofen on most days. The client is a heavy cigarette smoker.

The client had an abdominal hysterectomy 1 day ago. The client is crying in pain about 20 minutes before pain medicine is due. The client crying in pain or recovering from surgery 1 day ago would warrant a nursing diagnosis of Acute Pain. Pain that a client might be experiencing from past back surgery would be chronic and would not support the diagnosis of Acute Pain. Just because a client has a history of a painful condition, such as osteoarthritis, does not mean that the client is currently in acute pain. Being a heavy smoker does not support the diagnosis of Acute Pain.

The nurse is responsible for recognizing significant data when developing nursing diagnoses. Which significant data would indicate a health problem may exist? Select all that apply. The client has a blood pressure reading of 150/90 mm Hg. During assessment, the client is sweating and short of breath. The client only answers yes or no questions. The client's urine output of 30 mL per hour is recorded. The client has an oral temperature of 98.7°F (37.0°C).

The client has a blood pressure reading of 150/90 mm Hg. During assessment, the client is sweating and short of breath. The client only answers yes or no questions. The subjective and objective data that would be considered significant in this scenario are elevated blood pressure, sweating and shortness of breath, and client responses. Individually, each of these data may not be considered abnormal. However, as a cluster they may indicate that a problem exists. The other findings are within normal range and do not signify a problem at this time.

A client has been admitted to a hospital due to an acute psychotic episode. Which assessment data would the nurse identify as this client's strengths? Select all that apply. The client has been living on the street for 3 weeks. The client is male and 35 years old. The client has ample financial resources. The client refuses to take the ordered medication. The client is willing to attend counseling sessions.

The client has ample financial resources. The client is willing to attend counseling sessions. The client's financial resources and willingness to attend counseling will be positive factors in the client's recovery. The lack of a stable living environment would lessen the chance for compliance with the health care regimen once discharged. The client's refusal to take medication would not allow the health care providers to implement an important part of this client's treatment. That the client is male and 35 years old is neither a strength nor a weakness.

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 states that no one should ever ask for help from others. 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 a long history of health problems. The client has demonstrated effective coping skills in the past.

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. 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.

The nurse is caring for a client who underwent surgery 1 day ago. Which client problem can be addressed by independent nursing diagnoses? The client has a temperature of 101°F (38.3°C). The client has diminished breath sounds. The client has a blood pressure of 160/95 mm Hg. The client is requesting medication for pain.

The client has diminished breath sounds. The client's diminished breath sounds can be addressed by the independent nursing interventions of turn, cough, and deep breathe. The temperature, elevated blood pressure, and pain medication will require orders from the health care provider.

A nursing diagnosis of "Complicated Grieving" has been identified for a client whose spouse died 1 year ago. What assessment data would be appropriate evidence to justify this diagnosis? Select all that apply. The client states, "I miss my wife every day." The client no longer indulges in usual activities. The client attempted suicide 1 month ago. The client keeps a picture of the client's wife at the bedside. The client states, "I have no interest in doing anything."

The client no longer indulges in usual activities. The client attempted suicide 1 month ago. The client states, "I have no interest in doing anything." Still grieving the loss of a spouse after 1 year is a normal manifestation of grief. Keeping a picture of the spouse is also normal. No longer indulging in usual activities, attempting suicide, and stating that one has no interest in doing anything are signs of depression and unresolved grief.

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." The client asks for information relating to the cancer diagnosis. The client requests the minister of the client's church to visit.

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

A client diagnosed with advanced lung cancer has a nursing diagnosis of Ineffective Coping. What assessment data would provide evidence to the nurse for this diagnosis? The client asks about hospice services. The client makes funeral plans. The client states, "I am sure the doctors have misdiagnosed me." The client states, "I hope that I am able to attend my daughter's wedding."

The client states, "I am sure the doctors have misdiagnosed me." Denying the illness by stating a belief that the cancer diagnosis is incorrect is evidence that the client is not dealing with the illness. Inquiring about hospice and making funeral plans shows acceptance of the advanced stage of the illness. Stating a hope to attend the daughter's wedding is expressing hope for the future and is evidence of effective coping.

A client who gave birth yesterday refuses to eat the food provided by the hospital. The client reports needing special food brought from home by family. How would the nurse most appropriately address this situation? The nurse should not formulate a nursing diagnosis but should encourage the client to have family bring food from home. The nurse should formulate a possible nursing diagnosis and make further observations. The nurse should formulate an actual nursing diagnosis and plan interventions to correct the problem. The nurse should formulate a collaborative problem and consult with the health care provider and dietitian.

The nurse should not formulate a nursing diagnosis but should encourage the client to have family bring food from home. Many cultures require the new mother to eat specially prepared food. The client is simply following cultural practices. No health problem exists, so the nurse need not formulate a nursing diagnosis. Rather, practicing culturally respectful care, the nurse should encourage the client to have family members bring special food from home as hospital policies allow.

What is the purpose of establishing a nursing diagnosis? To describe a functional health problem To collaborate with the health care provider To identify medical problems To meet accreditation criteria

To describe a functional health problem Establishment of a nursing diagnosis reflects the synthesis of data gathered during a nursing assessment. Gordon suggested a framework for organizing nursing diagnoses based on functional health, thus offering a convenient way to cluster similar diagnoses. The purpose of establishing a nursing diagnosis is not to collaborate with the health care provider, identify medical problems, or to meet accreditation criteria. Nursing diagnoses relate to problems that the nurse can address independently using nursing interventions, so collaboration with the health care provider is not needed when developing them. Medical diagnoses, not nursing diagnoses, identify medical problems. Accreditation does not depend on establishing nursing diagnoses.

Assessment of a client with difficulty breathing reveals that the client has thick, tenacious secretions in the trachea and bronchi and excessive sputum with coughing. The respiratory rate is slightly increased. When developing this client's plan of care, which intervention would the nurse include? Assisted ambulation Limit fluids to 1,000 ml per day Tracheobronchial suctioning Mechanical ventilation

Tracheobronchial suctioning Based on the assessment of the client, the nurse should identify specific cues, such as thick secretions, excessive sputum, and coughing, that indicate a problem with the client's ability to maintain a clear airway. Tracheobronchial suctioning would be the appropriate intervention to clear the client's airway. The nurse would increase fluids to thin secretions, not limit fluid intake for this client. As the client is experiencing difficulty breathing, not problems with ambulation, assisted ambulation is not necessary. The client is breathing independently; therefore, mechanical ventilation is not necessary.

The nurse is developing and documenting a nursing diagnosis for a client. When formulating the nursing diagnosis, what guidelines should the nurse follow? Use accepted terms for the specific facility. Use only terms accepted by NANDA-I to state diagnoses and develop a nursing care plan. Do not use a computerized program to develop nursing diagnoses. Use NANDA-I nursing diagnoses to communicate the purposes of research and client care.

Use accepted terms for the specific facility. Current thinking states that accepted terms for nursing diagnoses may vary according to a school, employer, or specialty organization. It is no longer necessary for nurses to use only terms accepted by NANDA-I to state diagnoses or to communicate the purposes of research and client care. Standard terms in nursing are being developed and refined to facilitate computerization, research, and communication for client care. When a computerized program is used, nurses will need to learn the terms the program uses to represent diagnoses, outcomes, and interventions.

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 imprecise language Used a medical diagnosis Omitted defining characteristics Used legally inadvisable terms

Used legally inadvisable terms 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 Consisting of many interconnecting parts or elements Late, slow, or postponed Lack of proportion or relation between corresponding things

Weakened or damaged 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 formulates the nursing diagnosis: Disturbed Body Image related to decreased ability to cope with surgical removal of right breast as evidenced by client refuses to look at surgical site and client statement, "I'm ugly. My husband will no longer find me desirable." The decreased ability to cope with the removal of the breast is an example of: NANDA-I label. etiology. problem. defining characteristics.

etiology. The etiology identifies the factors that contribute to the unhealthy client response or problem. Disturbed Body Image identifies what is unhealthy about the client, or the problem, indicating the need for change. It is also the NANDA-I label. The client's statements and refusal to look at the surgical site are defining characteristics that validate the existence of the problem.

Can a nurse develop a nursing diagnosis when there is not enough evidence to support the presence of a problem, but the nurse would like to gather more evidence? Yes, this defines a risk diagnosis. No, a nursing diagnosis describes an existing problem. No, the nurse must have all of the evidence before formulating the diagnosis. Yes, this defines a possible nursing diagnosis.

Yes, this defines a possible nursing diagnosis. This is the definition of a possible nursing diagnosis. The statement is phrased the same way as an actual problem except that the "related to" phrase is "unknown etiology." 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/life processes. Nursing diagnoses can be formulated for both existing (actual) and potential (possible) problems. A nurse does not have to have all of the evidence before formulating the diagnosis.

A nurse sees the client grimace and documents that the client is in pain, without interviewing the client to obtain further cues. The nurse has: an impaired cluster interpretation. a lack of cues, or premature closure. an ineffective database. an inaccurate evaluation.

a lack of cues, or premature closure. The lack of adequate cues is called premature closure, which is the case in this situation, as the nurse only has one cue. There is no "cluster" of cues to interpret, so impaired cluster interpretation would not be accurate. It is not so much that the nurse's database is ineffective as it is that the database lacks sufficient data. Evaluation is a separate phase in the nursing process and does not pertain to diagnosis.

The nurse is caring for a client who is experiencing a collaborative problem. The nurse should plan the client's care based on an understanding that this problem is characterized by: an emergent condition that requires rapid nursing response. a risk or wellness human response to health problems. a result of disease, trauma, treatment, or diagnostic studies. a convenient means for communication among team members.

a result of disease, trauma, treatment, or diagnostic studies. The collaborative problem results from disease, trauma, treatment, or diagnostic studies. Collaborative problems require health care provider-prescribed and nurse-prescribed actions. The medical diagnosis requires and provides health care provider-prescribed actions for treatment. A nursing diagnosis describes a risk or wellness human response to health problems. Collaborative problems may or may not require immediate action. They do not necessarily provide a convenient means of communication among team members.

The nurse recognizes that health problems that the nurse can address by independent nursing interventions are called: dependent nursing diagnoses. actual or potential nursing diagnoses. collaborative nursing diagnoses. syndrome nursing diagnoses.

actual or potential nursing diagnoses. Nursing diagnoses are established based on actual or potential health problems that are identified by the nurse and can be independently addressed. Collaborative diagnoses are selected when the nurse needs to work with another member of the health care team 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 formulates the nursing diagnosis: Disturbed Body Image related to decreased ability to cope with surgical removal of right breast as evidenced by client refuses to look at surgical site and client statement, "I'm ugly. My husband will no longer find me desirable." The decreased ability to cope with the removal of the breast is an example of: NANDA-I label. etiology. problem. defining characteristics.

etiology The etiology identifies the factors that contribute to the unhealthy client response or problem. Disturbed Body Image identifies what is unhealthy about the client, or the problem, indicating the need for change. It is also the NANDA-I label. The client's statements and refusal to look at the surgical site are defining characteristics that validate the existence of the problem.

One major requirement of a nursing diagnosis is that it focus on a problem that is: established by the health care provider. based on the client's pathophysiology. legally treatable by registered nurses. included within the diagnosis-related group.

legally treatable by registered nurses. The scope of practice of registered nurses determines what interventions nurses are permitted to perform. Because nurses are responsible for addressing any problems they identify in their diagnoses, they may only include in their diagnoses problems that they may address using interventions that are within their scope of practice to perform. A nursing diagnosis may not be established by a health care provider or other non-nurse professional, is not based on the client's pathophysiology, and is not included within the diagnosis-related group,

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: inconsistent cues. premature closure. clustering of cues. cluster interpretation.

premature closure. Premature closure is when the nurse selects a nursing diagnosis before analyzing all of the pertinent information in the client's case. The nurse did not investigate any other information in this case before making 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. the problem's existence requires validation by the health care provider. the main focus is on monitoring the body's pathophysiologic response. the signs and symptoms of the disease are part of the information conveyed.

the interventions planned must be within the nurse's scope of practice. 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 health care provider that the problem exists, are focused on pathophysiologic responses of body organs and systems, and convey information about signs and symptoms of disease.

The nurse is caring for a hospitalized client. The nurse explains to the client that a care plan will be used for which reason(s)? Select all that apply. to improve the communication between nurses about the client's care needs to ensure a standard approach is taken in the care of all assigned clients to prevent any legal action the client may wish to take against the nurse to revise the care provided when planned interventions are not effective to ensure that the client is involved in decision making about care

to improve the communication between nurses about the client's care needs to revise the care provided when planned interventions are not effective to ensure that the client is involved in decision making about care Being transparent about the plan of care with each client is an important part of nursing care. When explaining the role of a nursing care plan to the client, the nurse will share that care plans are tools for communication between nurses. Effective communication between health care providers leads to better client outcomes. The nurse will explain that care plans are subject to revision. Planned interventions and standard approaches are not always effective for each client, even among clients with the same health issue. Care plans are intended to be customized to each client's unique care needs. A standard care plan template, however, should be used to ensure consistency. Evaluation helps to identify ineffective interventions and leads to a revision of the plan of care to facilitate better client outcomes. A written plan of care allows the client to be empowered and have a say in the decision-making process. The nurse will explain to the client that he or she is a part of the health care team and his or her input is captured in the plan of care. It would be inappropriate to explain to the client that a care plan prevents the client from taking legal action against the nurse. Although effective documentation is critical in ensuring nurses account for the care provided to clients, this is not the purpose of the care plan.

The nurse is aware that nursing diagnoses are: within the nursing scope of practice to develop and client-focused. collaborative and depend on the medical diagnosis. based on assessment data and the primary care provider's input. dictated by the medical diagnoses and change day by day.

within the nursing scope of practice to develop and client-focused. Nursing diagnoses are within the nursing scope of practice to develop and are client-focused. They are developed collaboratively with the client, are based on assessment data, and can change from day to day as the client's responses change. They are not do not depend on nor are they dictated by medical diagnoses, and they are not based on the input of the primary care provider.