NUR 209 Ch. 12 Diagnosing (Fundamentals of Nursing)
A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination? (page 258)
Bowel Incontinence
The nurse is providing care for a client who experienced an ischemic stroke 5 days ago. Which diagnosis would the nurse be justified in identifying and documenting in the care of this client? Select all that apply. (page 258)
Bowel Incontinence Impaired Swallowing Impaired Physical Mobility
A male client age 67 years has right lower quadrant pain that has been diagnosed as appendicitis and subsequently treated by open appendectomy. How should the nurse document a potential complication related to this client's diagnosis and treatment? (page 258)
"PC: Atelectasis related to surgery"
A client who gave birth yesterday refuses to eat the food provided by the hospital. She states that she must eat special food brought from home by her family. How would the nurse most appropriately address this situation? (page 269-270)
A client who gave birth yesterday refuses to eat the food provided by the hospital. She states that she must eat special food brought from home by her family. How would the nurse most appropriately address this situation?
Nurses write various types of nursing diagnoses depending on the client's condition. Which statements accurately describe types of NANDA-I nursing diagnoses? Select all that apply. (page 265-269)
A risk nursing diagnosis is a clinical judgment that concludes that an individual, family, or community is more likely to develop the problem than others in the same or similar situation. An actual diagnosis represents a problem that has been validated by the presence of major defining characteristics. A syndrome nursing diagnosis comprises a cluster of actual or risk nursing diagnoses that are predicted to be present because of certain events or situations.
A pregnant client asks the nurse for information on breastfeeding her baby. What type of nursing diagnosis would the nurse formulate? (page 266)
A wellness diagnosis
In the development and documentation of a nursing diagnosis, the nurse should follow which of the following guidelines? (page 270)
Accepted terms for nursing diagnoses may vary according to a school, employer, or specialty organization.
After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type? (page 266)
Actual
"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 diagnosis
The nurse recognizes that health problems that can be prevented by independent nursing interventions are called what? (page 255)
Actual or potential nursing diagnoses
The nurse recognizes that health problems that can be prevented by independent nursing interventions are called what? (page 255-256)
Actual or potential nursing diagnoses
The nurse is caring for a client who underwent abdominal surgery today. Which nursing diagnoses would be appropriate for the nurse to utilize? Select all that apply. (page 269-270)
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
While caring for a client admitted to the hospital for a fractured tibia, the nurse notes that the pattern of the client's blood pressure readings is consistently over the expected range for the client's age. How would the nurse most appropriately plan to care for this client? (page 259)
Address the collaborative problem PC: Hypertension.
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? (page 266-267)
Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor
The nurse caring for a client diagnosed with melanoma has identified a nursing diagnosis of "Ineffective Coping." What subjective assessment data would provide evidence for this nursing diagnosis? (page 264, 266-267)
Client's report of increased consumption of alcohol
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? (page 260-262)
Constipation related to irregular evacuation patterns
A nurse in the emergency room, who is unfamiliar with pediatric clients, assesses the vital signs of a 1-month old infant with a heart rate of 124 and a respiratory rate of 36. What would be the most appropriate measure for the nurse to take to analyze the significance of the infant's vital signs? (page 260)
Consult reference materials to determine the normal vital signs for 1-month old infants.
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? (page 258)
Consult with a more experienced nurse.
The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this baby, 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? (page 266)
Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement
While caring for a client admitted with Clostridium difficile infection, the nurse notes that the client has had 3 loose bowel movements in 3 hours. What would be the most appropriate nursing diagnosis to address this health problem? (page 266-267)
Diarrhea related to infectious processes secondary to Clostridium difficile infection as evidenced by 3 loose bowel movements in 3 hours
The nurse is planning care for a client who has experienced a myocardial infarction. Which of the following would be appropriate nursing diagnoses for the nurse to select for this client? Select all that apply. (page 270)
Fear related to change in health status Pain related to cardiac tissue damage
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? (page 258; 267-268)
High Risk for Injury related to unsafe home environment
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? (page 266)
Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis
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. What is the most appropriate nursing diagnosis? (page 270)
Hyperthermia
A nurse is interviewing an older adult client who has experienced a drastic weight loss following a CVA (cerebrovascular accident). The client states, "I have trouble getting groceries since I can no longer drive, so I don't have much food in the house." Based on this evidence, what would be the most appropriate nursing diagnosis? (page 270)
Imbalanced nutrition: Less than Body Requirements related to difficulty in procuring food
In the development of a nursing diagnosis for a client who has cachexia and decreased weight, what would be an appropriate nursing diagnosis? (270)
Imbalanced nutrition: less than body requirements
A nurse who is caring for a client admitted to the nursing unit with acute abdominal pain formulates the care plan for the client. Which of the following nursing diagnoses is the highest priority for this client? (page 270)
Impaired comfort
A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain that is interfering with her ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records? (page 256)
Impaired physical mobility related to pain
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? (page 258)
Ineffective Airway Clearance
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? (page 263)
Ineffective Health Maintenance related to client's denial of illness
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? (page 263. 266-267)
Ineffective Health Maintenance related to client's denial of illness
The nurse is caring for a client with AIDS (acquired immune deficiency syndrome) who frequently misses clinic appointments. The client states that transportation to the clinic is very difficult. What would be the nurse's most appropriate diagnosis? (page 263-269-270)
Ineffective health maintenance related to transportation difficulties
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? (266-267)
Knowledge deficit: Medications related to new medical diagnosis
The sclerae of a 3-day old infant have a yellowish tint and the nurse has just received an order to initiate phototherapy. Which nursing diagnosis will the nurse utilize to plan care for this client? (page 267-269)
Neonatal Jaundice
The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action? (page 254)
Notify the physician for additional orders
A client has been diagnosed with a recent myocardial infarction. What collaborative problem would be the priority for the nurse to address? (page 258, 270)
PC: Decreased cardiac output related to cardiac tissue damage
Which of the following nursing diagnoses is written incorrectly as a result of the health problem and etiology being reversed? (page 254)
Prolonged Immobility related to impaired skin integrity AEB 1-inch diameter open area on right buttocks surrounded by a 1-inch margin of redness; wound surface clean and beefy red; no drainage or foul odor detected.
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." In order to assure the safety of the client, what nursing diagnosis would the nurse address? (page 254)
Risk for Allergy Response related to latex allergy
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? (page 266)
Risk for Community Contamination related to possible environmental pollution
Which is an accurately phrased risk diagnosis?
Risk for Falls related to altered mobility
Which statement appropriately identifies an at-risk nursing diagnosis for a woman 78 years of age who is confined to bed? (page 266)
Risk for impaired skin integrity related to bed rest
Which of the following nursing diagnoses has the highest priority when caring for an older adult client with Alzheimer's disease? (page 270)
Risk for injury
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. (page 264)
The client attempted suicide 1 month ago. The client states, "I have no interest in doing anything." The client no longer indulges in his usual activities.
The nurse is caring for a client who underwent surgery 1 day ago. Which client problem can be addressed by independent nursing diagnoses? (page 254)
The client has diminished breath sounds.
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? (page 266)
The client states, "I am sure the doctors have misdiagnosed me."
The nurse has selected a nursing diagnosis of "Impaired Home Maintenance" for an older adult client. What assessment data would evidence this diagnosis? (page 266)
The nurse observes unsafe conditions in the client's home.
When reviewing the client's history, the nurse notes that it has been recorded that the client's last bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "Constipation," what assessment must the nurse make? (page 269)
The nurse should determine the client's normal bowel elimination pattern.
During morning report, the night nurse tells the day nurse that the client refused to allow the technician to draw blood for laboratory testing. What step would be essential for the day nurse to complete before selecting a nursing diagnosis to address this issue? (page 269-270)
The nurse should determine the reason for the client's refusal.
During a home health care visit, the nurse identifies a nursing diagnosis of Caregiver Role Strain for a parent who is caring for a child dependent on a ventilator. What subjective assessment data would support the nurse's diagnosis? (pages 264, 266-267)
The parent states, "I cannot allow anyone else to help because they won't do it right."
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 possible nursing 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: (page 260)
a lack of cues, or premature closure.
The nurse is aware that development of nursing diagnoses are: (page 257)
both within the nursing scope of practice and are client focused.
Which example of client care is not the responsibility of the nurse? (page 258)
confirming a medical diagnosis
A nurse makes a nursing diagnosis of Constipation after a client tells her he did not defecate on his last trip to the bathroom. The nurse has no other information on the client's defecation history. This is an example of:
premature closure
What is the purpose of establishing a nursing diagnosis? (page 256)
to describe a functional health problem
