CH 15 - Diagnosing PREP U
After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type?
Actual
A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination?
Bowel Incontinence Explanation: 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.
A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination? Bowel Incontinence Irritable Bowel Syndrome Ulcerative Colitis Small Bowel Obstruction
Bowel Incontinence Explanation: 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.
The nurse is providing care for a client who experienced an ischemic stroke 5 days ago. The client now has difficulty swallowing liquids and solids, has weakness on the right side of the body, and is incontinent of bowel and bladder. Which priority nursing diagnoses should the nurse identify and document in the care of this client? Select all that apply. Bowel Incontinence Dysphagia Impaired Swallowing Risk for Hemiparesis Impaired Physical Mobility
Bowel Incontinence Impaired Swallowing Impaired Physical Mobility
While caring for a client recovering from a cerebrovascular accident, the nurse determines that the client would benefit from the services of physical therapy. How should the nurse plan to involve physical therapy in the client's care? By formulating a collaborative problem By formulating an actual nursing diagnosis By formulating a medical diagnosis By formulating orders for physical therapy
By formulating a collaborative problem Explanation: When the nurse determines that the services of another health care discipline are necessary to aid the client to meet a health care need, the nurse formulates a collaborative problem. It is not an actual nursing diagnosis because the nurse cannot treat this problem independently. It is not in the nurse's scope of practice to make a medical diagnosis. Nurses do not write orders for physical therapy.
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? Identifying contributing factors Validating the nursing diagnosis Clustering significant data cues
Clustering significant data cues Explanation: Data clustering involves grouping client data or cues that point to the existence of a client health problem. When formulating a nursing diagnosis, the nurse identifies the client health problem related to an etiology and includes subjective and objective data that support the existence of the actual or potential health problem. The nurse identifies contributing factors in the etiology portion of the nursing diagnosis. The nurse validates the nursing diagnosis, often with the client, after a tentative one is formulated.
A client has been diagnosed with appendicitis and scheduled for an open appendectomy. How should the nurse document a potential complication related to this client's diagnosis and treatment? A client has been diagnosed with appendicitis and scheduled for an open appendectomy. How should the nurse document a potential complication related to this client's diagnosis and treatment?
"PC: Atelectasis related to surgery" Explanation: To write a diagnostic statement for a collaborative problem, focus on the potential complications of the problem. Use "PC" (for potential complication), followed by a colon, and list the complications that might occur. For clarity, link the potential complications and the collaborative problem by using "related to." "Client is at risk of impaired lung function due to anesthesia" could be risk statement but impaired lung function could also be a chronic problem. "Potentially complicated respiration as a result of surgery" is a vague diagnosis. "Risk for respiratory arrest due to anesthesia" would be relevant for the operating nurse and not a postoperative potential complication.
Which information ensures accuracy when the nurse is developing a nursing diagnosis?
A cluster of clinical cues Explanation: 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.
The nurse caring for a client with obesity would like to address the possible health problems that can develop related to obesity. To plan care for this client, what type of nursing diagnosis would the nurse formulate? A risk nursing diagnosis A possible nursing diagnosis A health promotion nursing diagnosis A problem-focused nursing diagnosis
A risk nursing diagnosis Explanation: Because the nurse is trying to address health problems that the client is at risk for because of obesity, the appropriate diagnosis is a risk nursing diagnosis. The nurse is not addressing a health problem that the client has or a health problem that the nurse needs more information to validate, so a problem-focused or possible nursing diagnosis is not appropriate. The client is not seeking health information, so a health promotion diagnosis is inappropriate.
"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? Potential nursing diagnosis Actual nursing diagnosis Health promotion nursing diagnosis Risk nursing diagnosis
Actual nursing diagnosis Explanation: 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.
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. Analyzing data Identifying indicators of potential dysfunction Organizing data Collecting subjective and objective data Identifying patterns
Analyzing data Identifying patterns Identifying indicators of potential dysfunction
Ask the client whether the heart rate is normal for the client. Compare the client's heart rate to that another teenaged client. Determine whether the client has any risk factors for cardiac disease. Have another nurse reassess the heart rate for accuracy.
Ask the client whether the heart rate is normal for the client. Explanation: 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 teenaged 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.
When planning initial care for a 16-year-old client and the client's newborn, the nurse formulates a nursing diagnosis of "Risk for Impaired Attachment." What would be the nurse's most appropriate action to take next?
Assess the client's interactions with the newborn. Explanation: To address a risk nursing diagnosis, the nurse is required to collect additional data. Observing the client's interactions with the newborn would be the most effective way to evaluate attachment. It is inappropriate to assume that the client's mother will be doing all the infant care, which would also be detrimental to the client's attachment to the infant. It is premature to initiate referrals to community services until further data are collected. It is also premature to develop a comprehensive education plan until the needs of the client are known.
While developing a plan of care for a client, what should the nurse do before selecting a nursing diagnosis? Perform a focused assessment related to the reason for admission. Establish short- and long-term client goals. Verify the primary care provider's written orders. Collect client subjective and objective data.
Collect client subjective and objective data. Explanation: Nursing diagnoses are developed as the second step of the nursing process. The first step is to collect all assessment data so that appropriate actual or potential nursing problems can be selected and addressed in the client's plan of care. Nursing diagnoses are not related to the medical diagnosis or the specific written orders from the primary care provider. Goals can only be established after the problem is identified. Although assessment--collecting subjective and objective client data--is necessary before developing nursing diagnoses, this assessment does not necessarily have to be a focused assessment.
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? Acute Confusion related to appropriate wound care Risk for Infection related to knowledge deficit Risk for sepsis related to local infection. Knowledge Deficit due to risk for infection
Confirming a medical diagnosis Explanation: 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.
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 Bowel incontinence related to depressive state Readiness for Enhanced Nutrition related to constipation Diarrhea related to client report of small, loose stools
Constipation related to irregular evacuation patterns Explanation: This client is experiencing constipation, which is having infrequent or difficult bowel movements, which the nurse believes to be caused by an irregular evacuation pattern--not having a bowel movement for 7 days. There is no evidence that the client needs, much less is ready for, enhanced nutrition related to constipation or that, by implication, that the client's constipation is caused by poor nutrition. There is no evidence that the client is experiencing bowel incontinence, depression, or diarrhea.
A newly graduated nurse is unable to determine the significance of data obtained during an assessment. What would be the nurse's most appropriate action? Consult with a more experienced nurse. Document the data for future reference. Contact the client's health care provider. Continue to collect assessment data.
Consult with a more experienced nurse. Explanation: A newly graduated nurse does not have the experience to interpret all data. The nurse must recognize when a consult with a more experienced nurse is needed. There is no evidence that the nurse needs to collect more data. The nurse must document the data, but if the data are significant and the nurse does not recognize this and takes no action, it could harm the client. There is no need to contact the health care provider at this time.
A newly graduated nurse is unable to determine the significance of data obtained during an assessment. What would be the nurse's most appropriate action? Continue to collect assessment data. Contact the client's health care provider. Document the data for future reference. Consult with a more experienced nurse.
Consult with a more experienced nurse. Explanation: A newly graduated nurse does not have the experience to interpret all data. The nurse must recognize when a consult with a more experienced nurse is needed. There is no evidence that the nurse needs to collect more data. The nurse must document the data, but if the data are significant and the nurse does not recognize this and takes no action, it could harm the client. There is no need to contact the health care provider at this time.
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 Disturbed body image Refusal of the client to look at the surgical site "I'm ugly. My husband will no longer find me desirable."
Decreased ability to cope with surgical removal of right breast Explanation: 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 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? Blood pressure of 84/46 mm Hg, heart rate of 145 beats/min, concentrated urine Hot, dry climate Deficient fluid volume Insufficient fluid intake
Deficient fluid volume Explanation: 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 nursing diagnosis is written incorrectly as a result of the health problem and etiology being reversed? Risk for Disturbed Body Image related to decreased ability to cope with surgical removal of right breast Pain related to tissue trauma and inflammation Risk for Injury related to lack of knowledge of crutch walking Prolonged Immobility related to impaired skin integrity
Describe the client's response to the health problem Explanation: Nursing diagnoses describe the client's response to the health condition, developmental stage, or life process and provide a convenient way to communicate nursing therapies or interventions, but does not include communicating treatment requirements. A nursing diagnosis describes an actual, risk, or health promotion human response to a health problem that nurses are responsible for treating independently. A medical diagnosis conveys information about the signs and symptoms of disease processes; it provides a convenient means for communicating treatment requirements and describes a disease or pathology of specific organs or body systems.
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 Injury related to urgent need for bowel evacuation Fluid Volume Excess related to diarrhea as evidenced by three loose bowel movements in 3 hours Risk for Infection Transmission related to high potential for communicability
Diarrhea related to infectious process as evidenced by three loose bowel movements in 3 hours Explanation: 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? Skin warm and dry Client reports being very sleepy Dressing intact with slight bloody discharge present Diminished breath sounds in left lower lobe Abdominal area soft with diminished bowel sounds throughout
Diminished breath sounds in left lower lobe Explanation: 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.
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? Knowledge Deficit: Cancer treatment options related to new diagnosis Ineffective Health Maintenance related to being overwhelmed by cancer diagnosis Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis Disturbed Self-Concept related to pancreatic cancer diagnosis
Disturbed Body Image related to loss of hair Explanation: The client has a problem with body image because of the loss of hair. The evidence would be the client's statement. The etiology cannot be a medical diagnosis, so the etiology of breast cancer would be incorrect. The other two statements do not contain an etiology. Nursing diagnoses must identify an etiology to direct the client's care.
When developing an appropriate nursing diagnosis, the nurse needs to keep in mind that:
Explanation: A nursing diagnosis describes an actual, risk, or health promotion response to a health problem that nurses are responsible for treating independently. Nursing diagnoses describe the client's response to the disease process, developmental stage, or life process and provide a convenient way to communicate nursing therapies or interventions. Nursing diagnoses carry legal ramifications. Only health care problems within the scope of nursing practice may be identified as nursing diagnoses. A nurse may not diagnose a medical disease and is not licensed to independently treat such a problem. Medical diagnoses, not nursing diagnoses, require validation by the physician that the problem exists, are focused on pathophysiologic responses of body organs and systems, and convey information about signs and symptoms of disease.
When developing nursing diagnoses, the nurse should focus on which area? Problem validation through physician collaboration Pathophysiological responses occurring in body systems Actions to be initiated for treatment Human responses to actual or potential health problems
Human responses to actual or potential health problems Explanation: The main focus of nursing diagnoses is on monitoring human responses to actual or potential health problems, whereas the main focus of medical diagnoses and collaborative problems is on monitoring the pathophysiological responses of body organs or systems. Actions to be initiated for treatment are the main focus for interventions or treatment. Collaboration with the physician to validate the problem reflects medical diagnoses or collaborative problems.
Which best describes the purpose of nursing diagnoses?
Identification of client problems that nurses can treat independently Explanation: 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.
When developing a nursing diagnosis for a client, which should the nurse do first? Validate the diagnosis Synthesize cue clusters Cluster the cues Identify the significant data
Identify the significant data Explanation: The first step in developing a nursing diagnosis is to look at the data for significant cues. After identifying significant data or cues, the nurse then groups the cues together to form meaningful clusters that describe specific client problems. Cluster interpretation involves synthesizing the cue clusters, to see the whole picture and attach meaning to the cluster. After developing the nursing diagnosis, the nurse should validate it with the client.
Which would be an appropriate nursing diagnosis for a client with cachexia and decreased weight? Lack of Adequate Nutrition Anorexia Nervosa Imbalanced Nutrition: Less than Body Requirements Weight Loss
Imbalanced Nutrition: Less than Body Requirements Explanation: The most appropriate nursing diagnosis would be Imbalanced Nutrition: Less than Body Requirements. Anorexia Nervosa is a medical diagnosis. Lack of Adequate Nutrition and Weight Loss are not standard terminology for nursing diagnoses.
A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain, which is interfering with the client's ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records?
Impaired Physical Mobility related to pain Explanation: "Impaired Physical Mobility related to pain" is the correct nursing diagnosis because it consists of an accurate descriptor, diagnostic label, and related factor. "Ineffective Movement related to arthritis" is an incorrect entry because the descriptor is incorrect and the diagnostic label is not approved. "Impaired Movements due to pain" is an inaccurate entry because the descriptor is inaccurate and the related factor is not written using approved words. "Ineffective Physical Mobility due to pain" has an erroneous diagnostic label and the related factors are written incorrectly.
Which assessment findings would support the nursing diagnosis of Impaired Skin Integrity? Select all that apply. Up with assistance to bedside commode Uncontrolled diabetes History of appendectomy Unable to turn in bed without assistance Impaired mobility due to recent stroke
Impaired mobility due to recent stroke Unable to turn in bed without assistance Uncontrolled diabetes
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 Asthma Attack Ineffective Airway Clearance Acute Dyspnea
Ineffective Airway Clearance Explanation: Because wheezing, shortness of breath, and coughing are signs of a constricted airway, the nursing diagnosis of Ineffective Airway Clearance is the appropriate diagnosis. Bronchial pneumonia and Asthma Attack are both medical diagnoses. Acute Dyspnea is a symptom.
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 Coping related to client's inability to manage the diabetic regimen Risk for Injury related to client's mismanagement of disease Ineffective Health Maintenance related to client's denial of illness
Ineffective Health Maintenance related to client's denial of illness Explanation: The most appropriate diagnosis is Ineffective Health Maintenance related to client's denial of illness. The data point to the fact that the client is not managing the diabetes, since the client denies that a problem exists. The client is at risk for unstable blood glucose, but the client's denial is the underlying problem. Risk for Injury relates to safety issues. It is also inappropriate documentation to say the client is "mismanaging" the illness. Ineffective Coping could be an appropriate diagnosis, but the client is not "unable" to manage the illness, just unwilling.
A nursing diagnosis of Ineffective Airway Clearance has been chosen by the nurse caring for a client with respiratory problems. Which assessment data would be appropriate evidence of this diagnosis? Select all that apply. Ineffective cough Labored respirations Oxygen at 3 L/min per nasal cannula Viral pneumonia Wheezes auscultated over all lung fields
Ineffective cough Wheezes auscultated over all lung fields Labored respirations
A teenager 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? 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 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
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 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? Assess the client's vital signs to determine the client's baseline. Ensure precautions are taken to prevent injury to the client. Determine the client's medical diagnosis for clarification. Interview the client's family to assess the client's usual level of cognition.
Interview the client's family to assess the client's usual level of cognition. Explanation: 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.
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?
It is part of nursing practice to interpret the significance of assessment data by comparing it to standards. The nurse should consult reference materials to determine the normal range of vital signs for this client. Deferring to the emergency room physician is unprofessional and may result in harm to the client. Asking the mother if the infant's vital signs are higher than normal is unprofessional practice. A complete physical assessment is not necessary at this time.
A nurse is planning education about prescription medications for a client newly diagnosed with asthma. What nursing diagnosis would be most appropriate for the nurse to select?
Knowledge Deficit: Medications related to new medical diagnosis Explanation: To most appropriately address the client's health problem, the nurse should educate the client about the new medications the physician has prescribed to treat the asthma. Ineffective Airway Clearance refers to the physiologic processes of asthma. There is no evidence of noncompliance. There is no indication that the client is having difficulty dealing with the diagnosis.
What is the nurse accountable for, according to state nurse practice acts? Prescribing PRN (as needed) medications Mentoring other nurses Making nursing diagnoses Managing the care team effectively
Making nursing diagnoses Explanation: State nurse practice acts have included diagnosis as part of the domain of nursing practice for which nurses are held individually accountable. Overall management of the care team is not an explicit responsibility of nurses. Nurses generally do not have prescriptive authority. The responsibility for mentorship is not enacted in law.
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 should the nurse use to plan care for this client? Risk for Visual Deficit Risk for Neonatal Jaundice Neonatal Jaundice Visual Deficit
Neonatal Jaundice Explanation: The yellow color of the sclera indicates jaundice, which is a common problem in the neonatal period. It is related to difficulties in bilirubin conjugation. "Risk for Neonatal Jaundice" is inappropriate because the client is already jaundiced. Jaundice signals liver dysfunction, not any problems with vision.
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? Decrease stimulation and allow the client to rest. Consult with another nurse to validate the assessment. Document the client's level of consciousness. Notify the physician for additional orders.
Notify the physician for additional orders. Explanation: The client's decreased level of consciousness could indicate that the client is developing an electrolyte imbalance. The change in the client's status requires notification of the physician. Medication orders are required to treat the electrolyte imbalance. Documenting the level of consciousness is appropriate, but not as the priority action. Another nurse is not necessary to check the nurse's assessment. Decreasing stimulation and allowing the client to rest with no further action may result in harm to the client.
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 write nursing diagnoses to describe client problems that nurses can treat. Nurses formulate nursing diagnoses to identify diseases. Nursing diagnoses focus on identifying healthy responses to health and illness.
Nurses write nursing diagnoses to describe client problems that nurses can treat. Explanation: Data collection leads the nurse to identifying client problems that the nurse is able to treat with planned nursing interventions, which is the focus of nursing diagnoses. Nursing diagnoses change as client goals are met or as new problems develop. Medical diagnoses identify disease processes.
A 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 assessment Nursing diagnosis Collaborative problem Medical diagnosis
Nursing diagnosis Explanation: The nursing diagnosis statement is worded by stating the client problem (using NANDA-I approved diagnoses) that the nurse is able to treat followed by the etiology of the problem. Nursing assessment refers to the collection of data. A medical diagnosis identifies diseases, whereas nursing diagnoses focus on unhealthy responses to health and illness. Nurses cannot treat medical diagnoses independently. Collaborative problems are the primary responsibility of nurses. Unlike nursing diagnoses, with collaborative problems, the prescription for treatment comes from nursing, medicine, and other disciplines.
A client 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 Explanation: 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 physician 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 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? Risk for Infection Transmission related to lack of immunizations Readiness for Enhanced Knowledge: Childhood Immunizations Ineffective Health Maintenance related to lack of knowledge of childhood immunizations Risk for Complications related to childhood illnesses
Readiness for Enhanced Knowledge: Childhood Immunizations Explanation: The community group is asking for information to enhance their health care habits. A health promotion diagnosis of Readiness for Enhanced Knowledge is indicated. There is no evidence of ineffective health maintenance practices. There is no evidence that the clients lack immunizations. Risk for Complications might result from a lack of immunizations, but that is not the issue being addressed here.
Which is a legal responsibility of a nurse who has documented a nursing diagnosis related to a client's kidney failure? Independently managing the client's kidney failure Reporting signs and symptoms related to 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
A pregnant client asks the nurse for information on breastfeeding. What type of nursing diagnosis should the nurse formulate?
Reporting signs and symptoms related to the client's kidney failure Explanation: In producing a nursing diagnosis, a nurse creates accountability for detecting and reporting the signs and symptoms of a medical diagnosis. The nurse is not legally responsible for independently managing or coordinating the client's treatment. Choosing and performing interventions to resolve the condition is primarily within the purview of the physician.
Which 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. Omitted the defining characteristics of the client health problem Wrote the diagnosis in terms of a need rather than a client response Identified environmental factors rather than client factors as the problem Reversed the health problem and the etiology
Reversed the health problem and the etiology Explanation: 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.
The care plan for a postoperative client includes a nursing diagnosis of "Risk for Urinary Retention." The nurse determines that the client has been voiding adequately. What is the nurse's most appropriate action?
Revise the nursing diagnosis because the client's status has changed. Explanation: The client is no longer exhibiting the health problem of "Risk for Urinary Retention." The nursing diagnosis is no longer valid and must be changed. It is no longer necessary to observe for urinary retention. There is no need for other disciplines, so a collaborative problem is unnecessary. Nurses do not consult with physicians about nursing diagnoses; it is the nurse's domain.
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 Risk for Injury related to latex allergy Knowledge Deficit related to surgical procedure Risk for Allergy Response related to latex allergy
Risk for Allergy Response related to latex allergy Explanation: To ensure the safety of the client, the nurse should address the risk for an allergic response due to the client's latex allergy. Anxiety refers to a vague feeling of dread; however, the client is responding with fear to a very real threat. There is no evidence that the client does not understand the surgical procedure. Risk for Injury is not an appropriate diagnosis, because it does not adequately address the specific health problem.
Which is an accurately phrased risk nursing diagnosis? Risk for Falls related to altered mobility Risk for Fluid Volume Excess related to increased oral intake as evidenced by consuming 3 L of soda Risk for Impaired Coping as evidenced by client crying Risk for Pain After Surgery
Risk for Falls related to altered mobility Explanation: Risk for Falls related to altered mobility is an accurately phrased risk nursing diagnosis. It is a two-part statement that contains the diagnostic statement (Risk for Falls) and risk factors (altered mobility).Two of the options (Risk for Impaired Coping and Risk for Fluid Volume Excess) incorrectly pair actual presenting manifestations, also called defining characteristics (client crying, consuming 3 L of soda), with a risk statement. Another option (Risk for Pain After Surgery) does not include a risk factor.
Which nursing diagnosis has the priority when caring for an older adult client with Alzheimer disease? Risk for Injury Impaired Memory Self-Care Deficit Impaired Physical Mobility
Risk for Injury Explanation: 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 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?
Risk for Powerlessness Explanation: The most appropriate nursing diagnosis for the client is the Risk for Powerlessness. The client feels that the disease is not under the client's control and any personal efforts will not affect outcome. Disturbed Body Image is not an appropriate answer because the client does not seem to be concerned about the appearance of the body. Impaired Comfort is also not an appropriate nursing diagnosis because the client does not demonstrate any sign of discomfort. There is not enough indication that the client is at risk for suicide.
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 is willing to attend counseling sessions. The client refuses to take the ordered medication. The client has ample financial resources. The client is male and 35 years old. The client has been living on the street for 3 weeks.
The client has ample financial resources. The client is willing to attend counseling sessions.
The nurse is formulating nursing diagnoses pertaining to a client with pancreatic cancer. Which factors should the nurse identify as strengths of the client? Select all that apply.
The client has been accompanied by family members to every appointment. The client states a belief in a reward in heaven after death. The client has demonstrated effective coping skills in the past.
A nurse is interviewing an older adult client who has experienced a drastic weight loss following a cerebrovascular accident (CVA). The client states, "I have trouble getting groceries because 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?
The client relates the drastic weight loss to the inability to bring food into the house. The client's statement is the most appropriate etiology for the nursing diagnosis. Drastic weight loss is the evidence of imbalanced nutrition. CVA is the medical diagnosis. The client could have had a CVA and still have the ability to grocery shop. There is no evidence that the client has lost appetite.
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 states, "I can't handle all of this." The client reports an inability to get adequate restful sleep. The client has difficulty concentrating on the details of treatment options. 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."
The nurse has selected a nursing diagnosis of "Impaired Home Maintenance" for an older adult client. What assessment data would evidence this diagnosis? The client lives with several extended family members. The client dislikes cleaning the home. The nurse observes that the client is confused. The nurse observes unsafe conditions in the client's home.
The nurse observes unsafe conditions in the client's home. Explanation: The observation of unsafe conditions indicates that the client is not effectively maintaining the home. The client's confusion may be a temporary condition and does not take into account any help the client has in maintaining the home. Living with family members provides a source of support for the client, which should assist in home maintenance. The client's distaste for housework does not mean that the client is not maintaining the home.
When reviewing the client's history, the nurse notes that the client's last documented bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "Constipation," what assessment must the nurse make?
The nurse should determine the client's normal bowel elimination pattern. Explanation: To validate the diagnosis, the nurse must determine what is normal for the client. Dietary habits may contribute to constipation, but the nurse must first confirm that the client is actually constipated. Likewise, bowel sounds might help explain the cause of constipation, but the nurse should first confirm that the client is constipated. There is no standard elimination pattern; it is highly individualized. Reference:
What is the purpose of establishing a nursing diagnosis?
To describe a functional health problem Explanation: 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 physician, 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 physician is not needed when developing them. Medical diagnoses, not nursing diagnoses, identify medical problems. Accreditation does not depend on establishing nursing diagnoses.
The nurse caring for a morbidly obese client formulates the possible nursing diagnosis, "Imbalanced Nutrition: More than Body Requirements related to excessive food intake as evidenced by morbid obesity." In order to assure the accuracy of the diagnosis, which further step must the nurse take? Determine what weight loss programs the client has utilized in the past. Validate with the client that excessive food intake is the cause of the client's obesity. Research the client's medical history to determine the client's usual weight. Interview the client to assess the client's motivation to lose weight.
Validate with the client that excessive food intake is the cause of the client's obesity. Explanation: The nurse must discuss the diagnosis with the client to ascertain whether or not the diagnosis is correct. There are other causes of obesity, such as a decrease in activity secondary to surgery. In order to plan effective interventions, it is important to determine the correct etiology. Determining the weight loss programs used by the client and the client's motivation to lose weight are important in planning interventions once the cause is determined. The client's usual weight is not relevant; the obesity may be longstanding.
When used in a nursing diagnosis, the descriptor "impaired" has which meaning?
Weakened or damaged Explanation: The descriptor "impaired" means weakened or damaged, such as in reference to a faculty or function. The descriptor "complicated" means consisting of many interconnecting parts or elements. The descriptor "delayed" means late, slow, or postponed. The descriptor "imbalanced" means lack of proportion or relation between corresponding things.
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:
a lack of cues, or premature closure. Explanation: 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:
a result of disease, trauma, treatment, or diagnostic studies. Explanation: The collaborative problem results from disease, trauma, treatment, or diagnostic studies. Collaborative problems require physician-prescribed and nurse-prescribed actions. The medical diagnosis requires and provides physician-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:
actual or potential nursing diagnoses. Explanation: Nursing diagnoses are established based on actual or potential health problems that are identified by the nurse and can be independently addressed. Collaborative diagnoses are selected when the nurse needs to work with another member of the health care team to assist the client in resolving the health issue. Dependent nursing diagnoses require a specific written order from the primary health care provider for a nurse to address. Syndrome nursing diagnoses address a cluster of actual or risk diagnoses that are predicted to be present as a result of a certain event or situation.
Cues that all relate to the same client problem may be grouped together in a process known as: categorizing. grouping. diagnosing. clustering.
clustering. Explanation: Cue clustering brings together cues that if viewed separately would not convey the same meaning. The cues are not being categorized or diagnosed. Grouping is not proper terminology.
One major requirement of a nursing diagnosis is that it focus on a problem that is:
legally treatable by registered nurses. Explanation: 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 physician or other non-nurse professional, is not based on the client's pathophysiology, and is not included within the diagnosis-related group,
A nurse is caring for a client who has pneumonia. What is an appropriate nursing diagnosis? Ineffective Airway Clearance Impaired Respiration Altered Airway Infection (Pulmonary)
neffective Airway Clearance Explanation: Ineffective Airway Clearance is a plausible nursing diagnosis for a client with pneumonia. The other listed options are not recognized NANDA nursing diagnoses.
A nurse makes a nursing diagnosis of Constipation after a client reports not defecating on the last trip to the bathroom. The nurse has no other information on the client's defecation history. This is an example of:
premature closure. Explanation: Premature closure is when the nurse selects a nursing diagnosis before analyzing all of the pertinent information in the client's case. The nurse did not investigate any other information in this case before making a diagnosis. Inconsistent cues occur when the meaning attached to one cue may be altered based on another cue. The nurse in this case only considered one cue, so inconsistent cues could not be the correct answer. Clustering of cues is a clustering of data; this nurse has only one cue, so the nurse cannot cluster data or interpret data clusters.
When developing an appropriate nursing diagnosis, the nurse needs to keep in mind that:
the interventions planned must be within the nurse's scope of practice. Explanation: A nursing diagnosis describes an actual, risk, or health promotion response to a health problem that nurses are responsible for treating independently. Nursing diagnoses describe the client's response to the disease process, developmental stage, or life process and provide a convenient way to communicate nursing therapies or interventions. Nursing diagnoses carry legal ramifications. Only health care problems within the scope of nursing practice may be identified as nursing diagnoses. A nurse may not diagnose a medical disease and is not licensed to independently treat such a problem. Medical diagnoses, not nursing diagnoses, require validation by the physician that the problem exists, are focused on pathophysiologic responses of body organs and systems, and convey information about signs and symptoms of disease.
When developing an appropriate nursing diagnosis, the nurse needs to keep in mind that: - the main focus is on monitoring the body's pathophysiologic response. - the problem's existence requires validation by the physician. -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.
the interventions planned must be within the nurse's scope of practice. Explanation: A nursing diagnosis describes an actual, risk, or health promotion response to a health problem that nurses are responsible for treating independently. Nursing diagnoses describe the client's response to the disease process, developmental stage, or life process and provide a convenient way to communicate nursing therapies or interventions. Nursing diagnoses carry legal ramifications. Only health care problems within the scope of nursing practice may be identified as nursing diagnoses. A nurse may not diagnose a medical disease and is not licensed to independently treat such a problem. Medical diagnoses, not nursing diagnoses, require validation by the physician that the problem exists, are focused on pathophysiologic responses of body organs and systems, and convey information about signs and symptoms of disease.
