Nursing Diagnosis (Ch. 7)
Which phrase best represents a related factor in a problem-focused nursing diagnosis? a. Unsteady gait requiring the assistance of two people b. Redness and swelling around the incision site c. Ineffective adaptation to recent loss d. Patient complaint of restlessness
c Related factors are broad statements that indicate the cause for the defining characteristics, which are signs or symptoms identified from collecting the patient's data. Redness and swelling, unsteady gait, and complaint of restlessness are specific defining characteristics that would be clustered with other data to support the existence of a problem-focused or health promotion nursing diagnosis.
What is the most significant problem that may result from improperly written NANDA-I nursing diagnostic statements? a. Lack of direction for formulating patient plans of care b. Omission of physician or primary care provider orders c. Combining of two unrelated patient concerns d. Increased team collaboration needs
a Accurate nursing diagnostic statements provide direction for the development of individualized plans of care. Orders are part of the patient's assessment data. Combining unrelated patient problems is a function of diagnostic development, not a result of an improperly written statement. Poorly written nursing diagnostic statements may or may not result in increased team collaboration.
What is the primary difference between a NANDA-I risk nursing diagnosis and a problem-focused nursing diagnosis? a. Related factors are not part of a risk diagnosis. b. There is no cause and effect relationship established. c. Defining characteristics are subjective in a risk diagnosis. d. There are no nursing interventions prescribed with a risk diagnosis.
a Risk diagnoses do not have related factors; problem-focused nursing diagnoses have both related factors and defining characteristics. Risk diagnoses do not establish a cause and effect because they identify potential rather than existing problems. Risk diagnoses identify risk factors (not defining characteristics), subjective or otherwise. Risk diagnoses, like problem-focused diagnoses, have nursing interventions that address a patient's current or potential problem.
Which actions does the nurse need to take before determining the types of nursing diagnoses that are applicable to a patient? (Select all that apply.) a. Review the patient's past and present medical history. b. Analyze the nursing assessment data to determine whether information is complete. c. Outline an individualized plan of care to address each concern. d. Consider potential complications to which the patient is susceptible. e. Evaluate how the patient has responded to treatment.
a, b, d Before determining the types of nursing diagnoses that are appropriate for a patient, the nurse must review and analyze all of the patient's data, including the medical history, for completeness and accuracy. Considering the vulnerability of a patient to potential complications permits the nurse to identify the need for risk nursing diagnoses. Outlining an individualized plan of care takes place during the planning stage of the nursing process after the nursing diagnoses have been identified. Evaluation of a patient's response to treatment is part of the evaluation stage of the nursing process.
A patient has just experienced a cardiac arrest on the unit. The nurse has implemented the acute care plan for management of code situations. What is the next step the nurse should take? a. Resume all interventions for previously identified nursing diagnoses. b. Perform the steps of the nursing process related to the patient's current condition. c. Seek physician input related to updating the nursing diagnosis statements. d. Evaluate the success of the acute care plan for management of the cardiac arrest.
b The patient's condition requires immediate performance of the lifesaving steps of the nursing process. All other answers are secondary actions. The nurse later resumes all interventions for previously identified nursing diagnoses and evaluates the success of the acute care plan for management of the cardiac arrest. Nurses do not seek the input of the physician for creation of nursing diagnoses.
Which nursing diagnosis statements are appropriately written according to 2018-2020 NANDA-I format? (Select all that apply.) a. Risk for Infection (ICNP) related to elevated temperature and white blood count b. Readiness for Effective Family Process (ICNP) as evidenced by an expressed desire for improved communication and mutual respect verbalized by family members c. Impaired health maintenance (ICNP) related to inability to access care as evidenced by failure to keep appointments, homebound status d. Risk for Hemorrhaging (ICNP) as evidenced by prolonged clotting time e. Chronic Pain (ICNP) related to osteoarthritis as manifested by verbalized postoperative discomfort
b, c, d Readiness for "Effective Family Process" is a health promotion nursing diagnosis and is written with two sections: the label and the defining characteristics. "Impaired health maintenance" is a problem-focused nursing diagnosis that requires a related factor and defining characteristics. "Risk for Hemorrhaging" requires at least one risk factor, which it has as it is written. Use of related factors in a risk nursing diagnosis is not the accepted NANDA-I format. The nursing diagnosis of "Chronic Pain" is incorrectly written because it includes a medical diagnosis and a related factor that is supportive of acute rather than chronic pain.
What signs and symptoms would the nurse appropriately cluster as supporting data for a patient with extreme anxiety? (Select all that apply.) a. Denies any difficulty falling asleep b. Elevated pulse rate auscultated at 140 bpm c. Continuous foot tapping throughout intake interview d. Demonstrates how to give insulin self-injection without hesitation e. Patient states, "I feel nervous all the time, especially when I am alone."
b, c, e An elevated pulse rate, continuous toe tapping, and verbalizing nervousness are consistent with extreme anxiety and should be clustered together. Ease of falling asleep and being able to focus on a challenging task, such as giving an injection, are not indicative of a patient experiencing a high level of anxiety.
Which statement best describes the relationship of medical diagnoses and nursing diagnoses? a. Medical diagnoses are imbedded in nursing diagnoses. b. Nursing diagnoses are derived from medical diagnoses. c. Medical diagnoses are not relevant to nursing diagnoses. d. Medical diagnoses may be interrelated to nursing diagnoses.
d Nursing diagnoses consider the underlying etiology, needs, potential concerns, and patient response to a patient's medical diagnosis, so the two types of diagnoses are interrelated. Medical diagnoses are not imbedded in nursing diagnoses, and nursing diagnoses are not derived from medical diagnoses, because that would limit the scope of assessment and care that is provided for patients. Nurses consider the medical diagnosis as one aspect of concern when identifying an existing or potential health problem and the patient's response, so medical diagnoses are relevant but not the focus of nursing diagnoses.
What is the most important reason for nurses to use a standardized taxonomy, such as the ICNP, CCC, or NANDA-I? a. Insurance documentation b. Professional autonomy c. EMR data analysis d. Patient safety
d Safety is the most important reason for using standardized language to communicate patient's needs and information. Using the same definitions of terms helps nurses and other health care professionals interpret the information. Helping with insurance documentation, supporting professional autonomy, and EMR data analysis are uses for ICNP, CCC, or NANDA-I taxonomy, but they are not the most important.
What is the most important action for a nurse to take to have a new nursing diagnosis considered for inclusion in the ICNP or NANDA-I taxonomies? a. Share concerns with the nurse manager on the nursing unit. b. Offer alternative care for a patient and family members. c. Discuss how to address patient needs with physicians. d. Provide evidence-based research to support nursing care.
d Supporting a suggestion for a new nursing diagnostic label with research is required for consideration by both ICNP and NANDA-I. Sharing concerns, providing alternative care, and advocating for patients are all a part of the nursing role but are not the most important part of having a diagnosis considered for inclusion in the ICNP or NANDA-I taxonomies.