Fundamentals of Nursing Chap 15

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.

Two limitations of Nursing Diagnosis are: 1. If used incorrectly, patient might be ________. 2. Nursing practice might be ________.

1. Misdiagnosed 2. Restricted

A pregnant client asks the nurse for information on breastfeeding. What type of nursing diagnosis should the nurse formulate?

A health promotion nursing diagnosis

Which of the following nursing diagnoses is written correctly? A. Child Abuse related to maternal hostility B. Breast Cancer related to family history C. Deficient Knowledge related to alteration in diet D. Imbalanced Nutrition related to insufficient funds in meal budget

Answer: D, Imbalanced Nutrition related to insufficient funds in meal budget Rationale: Answer A makes legally inadvisable statements, answer B is a medical diagnosis, and answer C reverses the clauses in the statement

A nurse is caring for an older adult client who is scheduled for a cystoscopy the next day to determine the cause of an overdistended bladder. The client expresses being nervous and informs the nurse that this the first time that the client has been admitted to a health care facility for an illness. Which diagnostic label would the nurse use to formulate the nursing diagnosis?

Anxiety

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.

This step of data interpretation is a grouping of patient data or cues that points to the existence of a problem (e.g., a series of readings)

Data Cluster

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?

Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement

Step 3 of formulating a nursing diagnosis is ________ _______ which identifies the subjective and objective data that signal the existence of a problem

Defining characteristics

Nursing Diagnosis

Describes patient problems nurses can treat independently

Medical diagnosis

Describes problems for which the physician directs the primary treatment

Which component of a nursing diagnosis gives additional meaning to the nursing diagnosis?

Descriptors

Step 2 of formulating a nursing diagnosis is _______ which identifies factors maintaining the unhealthy state

Etiology

Etiology

Factors that contribute to, or cause, health problems

Tell whether the following statement is true or false: The nursing diagnosis Risk for Imbalanced Nutrition: Less Than Body Requirements is an example of a risk diagnosis.

False Rationale: The nursing diagnosis "Risk for Imbalanced Nutrition: Less Than Body Requirements" is an example of a potential diagnosis.

The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping?

Health promotion nursing diagnosis

Collaborative problems

Issues managed by using physician-prescribed and nursing-prescribed interventions

What association meets every 2 years to further progress in defining, classifying, and describing nursing diagnoses?

NANDA International

Actual, Risk/possible, Wellness, Syndrome are the four types of ________ diagnosis.

Nursing Diagnosis

The nurse is aware that nursing diagnoses are within the ________ scope of practice to develop and ______ focused.

Nursing, Client

Step 1 of formulating a nursing diagnosis is the ________ which identifies what is unhealthy about the patient

Problem

PPMP stands for Predict, Prevent, Manage, and ________

Promote

A nurse decides that a patient has a possible problem with high blood pressure. During which step of data interpretation would this most likely be determined?

Reaching conclusions Rationale: A possible problem, such as high blood pressure, is diagnosed as a conclusion of data interpretation.

This step of data interpretation refers to the comparison of data to a standard or norm (e.g., normal blood pressure values)

Recognizing Significant Data

Nursing concerns and Responsibilities

Recognizing, Identifying, Anticipating, Initiating

When writing an actual nursing diagnosis, the nurse includes the etiology that contributes to the current situation. This would be identified as:

Related factors

Which statement appropriately identifies a risk nursing diagnosis for a client who is confined to bed?

Risk for Impaired Skin Integrity related to bed rest

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.

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?

Tracheobronchial suctioning

The nurse recognizes that health problems that the nurse can address by independent nursing interventions are called:

actual or potential nursing diagnoses