EAQ : Chapter 07 : Diagnosis

A patient with diabetes who underwent a lobectomy for lung cancer would be at risk for which complication?

A. Infection B. Atrial fibrillation C. Relapse of cancer D. Metastasis of cancer Answer: (A) Rationale Nursing diagnoses address conditions that are within the scope of nursing practice. Here, the patient is diabetic and has undergone surgery. Therefore the nurse can select a diagnostic label of risk for infection (ICNP). Nursing interventions should be planned for reducing the risk of infection. Risks of atrial fibrillation, cancer relapse, or metastasis are not within the scope of nursing care. (p. 92)

The nurse completed the following assessment: 63-year-old female patient has had abdominal pain for 6 days. She reports not having a bowel movement for 4 days, whereas she normally has a bowel movement every 2 to 3 days. She has not been hospitalized in the past. Her abdomen is distended. She reports being anxious about upcoming tests. Her temperature was 37°C, pulse 82 and regular, blood pressure 128/72. Which data form a cluster, showing a relevant pattern? Select all that apply.

A. Age of patient B. Abdominal pain C. Vital sign results D. Abdominal distention E. Change in bowel elimination pattern F. No past history of hospitalization Answer: (B, D, E) Rationale The presence of abdominal pain, distention, and a change in bowel elimination pattern forms a cluster, suggesting an elimination problem. The remaining assessment data collected by the nurse (patient age, vital signs, and hospitalization history) is unrelated to the elimination problem data. (pp. 94 -95)

Which skill is needed to help the nurse formulate a nursing diagnosis statement?

A. Clinical judgment B. Observation C. Communication D. Nursing experience Answer: (A) Rationale The nurse needs clinical judgment, which is based on patient assessment data, knowledge, and nursing experience, to formulate a nursing diagnosis statement. Observation and communication skills will help the nurse obtain accurate assessment data. Nursing experience by itself will not help formulate an accurate nursing diagnosis statement if the nurse lacks clinical judgment. (p. 94)

According to NANDA International Inc. (NANDA-I), which terms are the categories of sources of error that may occur in the nursing diagnostic process? Select all that apply.

A. Collecting B. Clustering C. Evaluating D. Interpreting E. Implementing Answer: (A, B, D) Rationale Collecting, clustering, and interpreting data are common sources of error in the nursing diagnostic process, according to NANDA-I. In the data collection process, errors occur due to a lack of knowledge or skills, inaccurate data, missing data, and disorganization. In clustering, errors may occur due to insufficient cluster of cues, premature or early closure, and incorrect clustering. In the interpreting process, error may occur due to inaccurate interpretation of cues, failure to consider conflicting cues, and the use of unreliable or invalid cues. Implementation and evaluation are part of the nursing process, not the nursing diagnostic process. (p. 91)

The nurse wants to formulate a risk nursing diagnosis statement for a patient with asthma. Which assessment would help the nurse formulate the second part of the diagnosis statement?

A. Current health status B. Potential risk factors C. Past health history D. Medication use Answer: (B) Rationale The second part of the risk nursing diagnosis statement contains the risk factors or potential risk factors, such as environmental or physical concerns that may make the patient vulnerable to a potential problem. The current health status will be stated with a diagnostic label in the first part of the diagnosis statement. Past health history is not included in the risk diagnosis statement. The use of medicines is an assessment data point that is not relevant to the diagnosis statement. (p. 92)

After reviewing and comparing defining characteristics gathered regarding a patient's pain symptoms, the nurse makes a nursing diagnosis of acute pain (ICNP). Which process helps the nurse avoid problems in the diagnostic process?

A. Data collection B. Data clustering C. Data interpretation D. Selecting a diagnostic label Answer: (C) Rationale In the review of data, the nurse compares defining characteristics for the two nursing diagnoses (acute pain [ICNP] versus chronic pain [ICNP]) and selects one based on the interpretation of data. The nurse should collect subjective and objective data first through physical assessment of the patient, interview of the patient and family members, and laboratory and diagnostic test results. After collecting and reviewing all the assessment data, the nurse looks for patterns and related data to support a specific nursing diagnosis. Selecting the diagnostic label will not help the nurse avoid problems. This step is the result of careful data collection, clustering, and interpretation. (p. 94)

A cluster of data contains only which information?

A. Data with a similar etiology B. Objective data C. Subjective data D. Data related to one body system Answer: (A) Rationale The nurse reviews the assessment data to look for patterns and related data to support specific nursing diagnoses. A cluster contains all the assessment data with similar etiologies. Each cluster will have a nursing diagnostic statement. Analysis of the assessment data may yield several clusters of related data for a patient. A cluster is a combination of both objective and subjective data that identify a single problem. A cluster may also contain data from different body systems and not just one body system. (p. 94)

Which factor would the nurse focus on when formulating a nursing diagnosis statement?

A. Disease B. Complication C. Physiologic event D. Response to a health problem Answer: (D) Rationale A nursing diagnosis focuses on a patient's response to a health problem. A nursing diagnosis provides a basis for selecting, planning, and implementing interventions. Diseases, complications, and physiological events are not the focus of formulating the nursing diagnosis. These components are part of a medical diagnosis. (p. 91)

According to NANDA International Inc. (NANDA-I), which statement describes a health-promotion diagnosis statement?

A. It describes a person's readiness to enhance specific health behaviors for well-being. B. It describes human responses to health conditions that may develop in a vulnerable individual. C. It describes human responses to health conditions that exist in an individual or community. D. It is associated with a potential response to the health problem and can change by using specific nursing interventions. Answer: (A) Rationale A health promotion nursing diagnosis statement is a type of nursing diagnosis that indicates a person's readiness to enhance specific health behaviors for well-being. A human response to health conditions that may develop in a vulnerable individual is a risk nursing diagnosis statement. A human response to health conditions that exist in an individual or community is a problem-focused nursing diagnosis statement. A potential response to the health problem that can change by using specific nursing interventions is a related factor. (p. 92)

Which statement describes a benefit of an accurate nursing diagnosis statement?

A. It eliminates the need for further assessment. B. t decreases the side effects of medications. C. It reduces the cost of treatment for the patient. D. It helps ensure effective and efficient nursing interventions. Answer: (D) Rationale An accurate nursing diagnosis helps ensure effective and efficient nursing interventions. Formulating the correct nursing diagnosis statement is based on proper assessment of the patient and proper analysis of the health problem. It enhances the nursing care provided to the patient. Further assessment after the nursing diagnosis is essential to evaluate the effectiveness of activities performed. Even accurate nursing diagnosis statements will not guarantee a decrease in the side effects of medications or reduce the cost of treatment. (p. 92)

Which statement describes the characteristic feature of a medical diagnosis?

A. It initiates treatments to prevent complications. B. It identifies physical and psychological illnesses. C. It considers the patient's attitudes and strengths. D. It makes judgments based on the actual condition. Answer: (B) Rationale A medical diagnosis identifies the physical and psychological illnesses of a patient. It is identified by a health care provider. A risk nursing diagnosis statement is formulated by the nurse and initiates treatments to prevent potential complications. The health-promotion nursing diagnosis statement is identified by the nurse. This diagnosis is not limited to the medical condition and considers the patient's attitudes and strengths, which are critical for planning holistic, individualized care. The problem-focused nursing diagnosis statement is also formulated by the nurse. This diagnosis makes clinical judgments based on the actual condition. (p. 92)

Which activity best assists the nurse in formulating the nursing diagnosis statement?

A. Obtaining patient data from the patient's families B. Clustering related patient assessment information C. Obtaining the past medical problems of the patient D. Understanding the objective patient data Answer: (B) Rationale The nurse formulates a nursing diagnosis statement by analyzing and clustering related assessment data. The nurse obtains patient data from medical records as well as from the patient and the family members to formulate an accurate diagnosis statement. The nurse obtains the past medical problems of the patient in a clinical interview. The nurse collects subjective as well as objective patient data during the assessment to formulate a diagnosis statement. (p. 92)

Which category of data would the nurse recognize as a "related factor" in the nursing diagnosis statement?

A. Physical B. Etiological C. Psychological D. Environmental Answer: (B) Rationale The second part of the nursing diagnosis statement is the "related factors." The nurse identifies the underlying cause or etiology of a patient's problem as a related factor. The risk nursing diagnosis consists of two parts: the diagnostic label and the risk factors. The risk factors include physical, psychological, and environmental factors. A patient with compromised health is susceptible to complications caused by risk factors. For example, risk factors such as advanced age and low blood pressure can cause an elderly patient to fall. STUDY TIP: Think of the related factors as the "because of" factors; so a diagnosis exists because of the underlying cause or etiological factors. To help you remember this, realize that you are related to other people in your family because of your shared family heritage. (p. 94)

In addition to selecting the diagnostic label, which criteria would the nurse consider when writing a health-promotion nursing diagnosis statement?

A. Risk factors B. Related factors C. Defining characteristics D. Related factors and defining characteristics Answer: (C) Rationale The nursing diagnosis statement contains two or three sections. The nurse includes the diagnostic label and defining characteristics when writing a health-promotion nursing diagnosis statement. The diagnostic label is a term or phrase that represents a pattern of clustered data. This term is taken from a list of approved nursing diagnostic labels. Defining characteristics are clusters of related data that may be signs, symptoms, or indications of a desire on the part of the petite to improve their health status. The risk nursing diagnosis statement has two segments: a diagnostic label and related risk factors. The problem-focused nursing diagnosis statement is written in three parts: the diagnostic label, the related factors, and the defining characteristics. (p. 93)

The nurse formulates a nursing diagnosis statement for a patient with severe pain due to a femur fracture as evidenced by grimacing. Which phrase would the nurse include in the "defining characteristics" segment of the diagnosis statement?

A. Severe pain B. Related to C. Grimacing D. Femur fracture Answer: (C) Rationale Health promotion diagnoses are clinical judgements concerning the motivation and desire of an individual, family, group, or community to increase well-being and to actualize human health potential. The third part of the nursing diagnostic statement is the defining characteristic of the nursing diagnosis. Defining characteristics are clusters of related data that are signs or symptoms of a health-promotion nursing diagnosis. The nurse can see a patient grimace; therefore it is deemed objective data. Severe pain is the diagnosis label. A diagnostic label describes the diagnostic focus and requires nursing judgment before it is assigned to a patient. The phrase "Related to" introduces related factors or underlying cause or etiology of a patient's problem. A fractured femur is the underlying cause of the patient's severe pain. (p. 94)

Which factor would the nurse consider while formulating a problem-focused nursing diagnosis statement for a patient?

A. The existing problems of the patient B. The possibility of potential complications C. The need for positive change in the patient D. The need for change in the patient's family Answer: (A) Rationale The nurse identifies the existing problems of the patient when preparing a nursing diagnosis statement to create an individualized plan of care. The nurse identifies the vulnerability of the patient or the possibility of potential complications when preparing a risk nursing diagnosis statement. This diagnosis guides the initiation of treatments to avoid potential problems. When a positive change in behavior can improve the patient's health, the nurse prepares a health-promotion diagnosis statement. A health-promotion nursing diagnosis statement may also be applied to the patient's family. (p. 92)

The nurse is assessing a patient who states, "I feel so lonely without my spouse, and it's been keeping me awake at night." The patient has an introverted personality and has a family history of substance abuse. Which conclusion would the nurse make regarding this data?

A. The patient is at risk for suicide. B. The patient has a loss of appetite. C. The patient is hallucinating. D. The patient is at risk for insomnia. Answer: (A) Rationale The patient displays symptoms that increase the risk for suicide. The patient may be experiencing a loss of appetite, which could result in weight loss; however, this information is not listed as a finding by the nurse. The patient is not experiencing hallucinations. The patient is experiencing loneliness due to the loss of a spouse. The patient complains of not sleeping well (sleep disturbances); therefore the patient is not at risk for insomnia, but is currently experiencing it. (p. 95)

Which risk does the nurse identify in an older patient with limited physical mobility?

A. The patient may experience bleeding. B. The patient may develop an infection. C. The patient may experience nausea. D. The patient may develop constipation. Answer: (D) Rationale An older patient with limited physical movement is likely to develop constipation because decreased mobility affects peristalsis and frequency of bowel movements. The patient may develop bleeding if there is an injury or a clotting abnormality. The patient is likely to develop an infection in the presence of a wound or surgical incision. The patient may experience nausea related to side effects from medications. STUDY TIP: Remember this saying: "You've got to move to move!" In other words, physical activity helps keep bowel movements regular. This applies to nursing students as well as patients, so do your best to get some exercise today. (p. 95)

Which factor would the nurse consider when writing a health-promotion nursing diagnosis statement?

A. The patient's current need B. The chance of complications C. The desire for lifestyle changes D. The response to a current need Answer: (C) Rationale The health-promotion nursing diagnosis statement is based on the desire expressed by the patient or family for a change in lifestyle that will improve the patient's health. The nursing diagnosis addresses the patient's current need or health problem. The risk nursing diagnosis addresses the chance of complications or potential risks in a patient due to the current health problem. The nursing diagnosis addresses the response of the patient to the current need or life process. STUDY TIP: Laughter is a great stress reliever. Watching a short program that makes you laugh, reading something funny, or sharing humor with friends helps decrease stress. It also promotes lymph circulation, so encourage laughter in yourself and your patients in your quest for health promotion. (p. 92)

Which phrase describes the purpose of risk nursing diagnoses?

A. To identify potential problems of the patient B. To identify past diseases that the patient had C. To identify healthy behaviors in the patient D. To identify the current needs of the patient Answer: (A) Rationale Risk nursing diagnoses identify risk factors that are vulnerabilities of an individual, family, group, or community for developing negative human responses to health conditions or life processes. The nurse uses risk nursing diagnoses to identify potential problems or risks that may develop in the patient. The nurse will identify past diseases in the patient during a clinical interview. The nurse will also understand healthy behaviors in a patient during an assessment. Careful consideration of the patient's subjective and objective assessment data identifies if a patient has an existing or potential problem or is seeking help to improve his or her lifestyle or situation. STUDY TIP: A risk nursing diagnosis means the patient is at risk of developing a problem in the future because of the patient's current status. That problem does not yet exist, though, so it is a potential problem. (p. 92)