Prep U Ch.15 NRS 201
A client is caring for the client's mother-in-law, who is an older adult who requires assistance with peforming activities of daily living. Which statement by the client would lead the nurse to make a nursing diagnosis of Caregiver Role Strain?
"I just don't have time to take a shower." Any of these statements could be a clue to caregiver role strain when clustered with other evidence. However, the inability to care for oneself, such as not taking time for a shower, strongly indicates that this client is not coping well.
A pregnant client asks the nurse for information on breastfeeding. What type of nursing diagnosis should the nurse formulate?
A health promotion nursing diagnosis The client is seeking information related to healthy practices. Health promotion nursing diagnoses are formulated to assist the client to meet that need. The client has no health problem, risk of a health problem, or possible problem, so a problem-focused, risk, or possible nursing diagnosis would be inappropriate.
A client who recently became quadriplegic as the result of a motor vehicle accident is experiencing multiple physical and emotional problems. To guide the care planning for this client, what type of nursing diagnosis would be most appropriate for the nurse to select?
A syndrome nursing diagnosis Because the client is experiencing multiple problems beyond the scope of a single nursing diagnosis, a syndrome diagnosis is indicated. A problem-focused diagnosis, which addresses only one problem, is not sufficient. The client has identified actual problems, so a possible or risk nursing diagnosis would be inappropriate.
A nurse is using Gordon's functional health patterns as an organizing framework for client assessment. The client has significant problems related to breathing, for which the nurse identifies several nursing diagnostic labels, including Ineffective Breathing Pattern and Impaired Gas Exchange. The nurse understands that these nursing diagnoses would be organized under which functional pattern?
Activity-exercise Nursing diagnoses involving ineffective breathing pattern and impaired gas exchange would be organized under the pattern of activity-exercise, which addresses the pattern of activity, exercise, leisure, recreation, and activities of daily living. Nutritional-metabolic involves nursing diagnoses associated with weight, eating, fluids, and skin and tissue integrity. Coping-stress tolerance addresses coping, resilience, suicide, and self-mutilation. Cognitive-perceptual addresses pain, neurological issues, impulse control, knowledge, and decision-making.
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 "Ineffective Airway Clearance related to thick tracheobronchial secretions" is an actual nursing diagnosis, because it describes a human response to a health problem that is being manifested. A health promotion nursing diagnosis is a diagnostic statement that describes the human response to levels of wellness in an individual, family, or community that has a potential for enhancement to a higher state. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. A possible nursing diagnosis is made when not enough evidence supports the presence of the problem, but the nurse concludes that it is highly probable and wants to collect more information.
"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 nursing diagnosis 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 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?
Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor The most appropriate diagnosis would be "Bathing Self-care Deficit. The client is homeless and would not be able to access bathroom facilities. Homelessness has not been identified as a syndrome and there is only evidence of one problem. Inadequate hygiene has not been identified as a nursing diagnosis; furthermore, the word "stink" is an offensive term that must be avoided in nursing documentation. There is no evidence to suggest that the client has any issues with impulse control.
A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination?
Bowel Incontinence 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.
Which type of health problem requires both physician- and nurse-prescribed actions to address?
Collaborative health problem If a problem requires both physician- and nurse-prescribed actions to address, it is by definition a collaborative health problem. The other answers listed are not standard types of health problems.
While developing a plan of care for a client, what should the nurse do before selecting a nursing diagnosis?
Collect client subjective and objective data. 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.
Which example of client care is not the responsibility of the nurse?
Confirming a medical diagnosis 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 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 movment for 7 days. There is no evidence that the client needs, much less is ready for, enhanced nutrition related to constpation 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 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?
Consult reference materials to determine the normal vital signs for 1-month old infants. 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 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. 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 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 The client's statement indicates that it is difficult for the client to reach a decision because of the client's moral beliefs. The client is not expressing hopelessness or demonstrating ineffective coping or complicated grieving. The client may be suffering from rape trauma syndrome, but the assessment data do not lead to that diagnosis.
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 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.
Which is true of nursing diagnoses?
Describe the client's response to the health problem 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.
Which component of a nursing diagnosis gives additional meaning to the nursing diagnosis?
Descriptors Descriptors are words used to give additional meaning to a nursing diagnosis through adding conditions and showing relationships between events. The other answers listed are not components of a nursing diagnosis.
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?
Diminished breath sounds in left lower lobe 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 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?
Disturbed Body Image related to loss of hair 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.
A nurse documents the following nursing diagnosis on a client's plan of care: "Fluid Volume Deficit related to gastrointestinal upset from food poisoning as evidenced by vomiting and diarrhea for the past three days, slow skin turgor, and weight loss." The nurse identifies which part of the statement as the etiology?
Gastrointestinal upset from food poisoning The etiology identifies the physiological, psychological, sociological, spiritual, and environmental factors believed to be related to the problem as either a cause or a contributing factor. The problem is fluid volume deficit. Vomiting and poor skin turgor are defining characteristics.
A nurse documents the following nursing diagnosis on a client's plan of care: "Readiness for Enhanced Breast-Feeding." The nurse has identified which type of nursing diagnosis?
Health promotion A health promotion nursing diagnosis is a clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential. These responses are expressed by a readiness to enhance specific health behaviors and can be used in any health state. A problem-focused nursing diagnosis is a clinical judgment concerning an undesirable human response to a health condition or life process that exists in an individual, family, group, or community. A risk nursing diagnosis is a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions or life processes. A syndrome nursing diagnosis is a clinical judgment concerning a specific cluster of nursing diagnoses that occur together and are best addressed together and through similar interventions.
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?
High Risk for Injury related to unsafe home environment The nursing diagnosis "High Risk for Injury related to unsafe home environment" is appropriate because it contains the NANDA-I nursing diagnosis problem statement and the etiology of the problem. High Risk for Injury related to abusive parents is accusatory and may not be accurate. High Risk for Injury related to impaired home management does not accurately identify the etiology of the problem. Child Abuse is not a NANDA-I approved nursing diagnosis.
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?
Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis The client is expressing a lack of hope for the future, which makes "Hopelessness" an appropriate nursing diagnosis. There is no evidence that the client has a disturbed self-concept. There is no evidence that the client is not effectively caring for health. The client does not verbalize a desire to learn about treatment options.
When developing nursing diagnoses, the nurse should focus on which area?
Human responses to actual or potential health problems 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 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?
Identify the significant data 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?
Imbalanced Nutrition: Less than Body Requirements 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 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?
Imbalanced Nutrition: Less than Body Requirements related to difficulty in procuring food 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 nurse, who is caring for a client admitted to the patient care unit with acute abdominal pain, formulates the care plan for the client. Which nursing diagnosis is the priority for this client?
Impaired Comfort Acute pain in the abdomen disturbs all the systems of the body. Relieving the pain should be the nurse's first priority. According to Maslow, physiologic needs are the highest priority. The client may have Disturbed Body Image, Disturbed Sleep Pattern, or Activity Intolerance, but all these are secondary to pain.
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 "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.
A nurse is interviewing an asthmatic client who has a high respiratory rate and is having difficulty breathing. The client is consequently restless and can only speak a few words before pausing to catch a breath. What appropriate nursing diagnosis should the nurse document?
Impaired Verbal Communication related to the breathing problem The client has a high respiratory rate and difficulty breathing; the client therefore has trouble communicating. Impaired Verbal Communication related to the breathing problem is the appropriate diagnosis. Although Impaired Gas Exchange may occur in an asthma attack, it does not relate to the concern regarding the client's ability to communicate nor would it be of primary concern in this case. There is no evidence that the client is experiencing Impaired Physical Mobility due to the condition. Inability to Speak due to ineffective airway clearance is not a properly structured nursing diagnosis (it should include "related to" rather than "due to") and is not accurate, in that the client is able to speak, although the speech is impaired.
Which are benefits of using nursing diagnoses when creating the nursing care plan? Select all that apply.
Improves communication between nurses caring for the client Directs areas of nursing research Encourages the client's participation in care By providing a standard terminology, nursing diagnoses enable nurses to understand each other. Nursing diagnoses can help direct nursing research by identifying issues that should be addressed. Nursing diagnoses encourage the client's participation in care because validation by the client is required. Nursing diagnoses require legal accountability of the nurse because the nurse has identified a problem and is required to treat it. Nursing diagnoses do not affect the care given by members of other disciplines.
Which is the best example of a nursing diagnosis?
Ineffective Breastfeeding related to latching as evidenced by nonsustained suckling at the breast. Ineffective breastfeeding contains all the correct and necessary components of a nursing diagnosis. Both Gastroesophageal Reflux and Cellulitis are medical diagnoses. Ineffective Airway Clearance is an appropriate diagnostic label. However, a client not speaking does not match the diagnosis.
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?
Ineffective Health Maintenance related to client's denial of illness 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.
Which nursing diagnosis(es) is correctly written with its three parts? Select all that apply.
Ineffective Health Maintenance related to lack of motivation as evidenced by client's statement of lack of interest in improving health Constipation related to side effects of antidepressants as evidenced by passage of hard, dry stool The Ineffective Health Maintenance and Constipation diagnoses are correctly written. They each consist of a valid nursing diagnosis, an appropriate etiology, and evidence that validates the diagnosis. Bowel Incontinence diagnosis is incorrectly written because the etiology is a medical diagnosis. Asthma is not a nursing diagnosis; it is a medical diagnosis. The Activity Intolerance diagnosis lacks evidence that would make it a three-part nursing diagnosis.
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?
Ineffective health maintenance related to transportation difficulties Ineffective health maintenance related to transportation difficulties is the correct answer. The client is having difficulty coming to clinic appointments necessary to monitor the progression of AIDS. The client states the cause of the missed appointments is transportation difficulties. The client does have AIDS, but that is not why the appointments are missed. The client is at risk for noncompliance with the prescribed therapy, but the actual diagnosis of "Ineffective health maintenance" is most appropriate to address the situation.
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 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?
Making nursing diagnoses 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 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?
Notify the physician for additional orders. 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?
Nurses write nursing diagnoses to describe client problems that nurses can treat. 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 diagnosis 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 has been diagnosed with a recent myocardial infarction. What collaborative problem would be the priority for the nurse to address?
PC: Decreased Cardiac Output related to cardiac tissue damage All these collaborative problems may be indicated for a client with a recent myocardial infarction; however, priority must be given to life-threatening issues. Decreased cardiac output is the only life-threatening problem among the answer options, so it must be the priority.
A nurse suspects that a client has a self-care deficit, but needs more data to confirm this diagnosis. What nursing diagnosis would the nurse write for this client?
Possible Possible nursing diagnoses are statements describing a suspected problem for which additional data are needed. Additional data are used to confirm or rule out the suspected problem. An actual nursing diagnosis means that there is data to support a client's actual health care problem. NANDA-I describes five types of nursing diagnoses: actual, risk, possible, health promotion, and syndrome.
Which nursing diagnosis is written incorrectly as a result of the health problem and etiology being reversed?
Prolonged Immobility related to impaired skin integrity Impaired Skin Integrity related to prolonged immobility is the correct format. Prolonged immobility contributes (etiology) to impaired skin integrity (problem), but the impaired skin integrity does not contribute to prolonged immobility. The other nursing diagnoses are correct.
Which is a legal responsibility of a nurse who has documented a nursing diagnosis related to a client's kidney failure?
Reporting signs and symptoms related to the client's kidney failure 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.
Reversed the health problem and the etiology 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 defninig 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.
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?
Risk for Allergy Response related to latex allergy 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.
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?
Risk for Community Contamination related to possible environmental pollution The nurse has identified a risk diagnosis because of the unknown health effects of the chemical plant on the community. Risk for Community Contamination would address the broad concerns of the nurse. Knowledge Deficit is not appropriate because it has too narrow a focus. Deficient Community Health is not a NANDA-I diagnosis and the etiology must deal with how the plant may possibly affect the community. Risk for Infection has a very narrow focus. The etiology of community contamination has not been proven.
Which is an accurately phrased risk nursing diagnosis?
Risk for Falls related to altered mobility 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 statement appropriately identifies a risk nursing diagnosis for a client who is confined to bed?
Risk for Impaired Skin Integrity related to bed rest A risk nursing diagnosis, as defined by NANDA-I, "describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community." The client in this scenario is most at risk for skin breakdown related to prolonged confinement to bed; however, proactive and continued nursing interventions can reduce this risk. Ineffective Airway Clearance and Immobility are not risk nursing diagnoses but actualy nursing diagnoses, as they describe problems that already exist. Potential for Pneumonia is not a properly worded risk nursing diagnosis; "Risk for" should be included rather than "Potential for."
A nurse is educating a client about care to be taken in nephrotic syndrome. The client expresses that the education is of no use because the disease is not curable. What nursing diagnosis should the nurse formulate with regard to the client's concern?
Risk for Powerlessness 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 has ample financial resources. The client is willing to attend counseling sessions. The client's financial resources and willingness to attend counseling will be positive factors in the client's recovery. The lack of a stable living environment would lessen the chance for compliance with the health care regimen once discharged. The client's refusal to take medication would not allow the health care providers to implement an important part of this client's treatment. That the client is male and 35 years old is neither a strength nor a weakness.
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. The client's support by family members, a belief in an afterlife, and demonstration of effective coping skills in the past are indications that the client will be able to cope with this illness. The client's belief in never asking for help will cause excessive isolation from others. The client's long history of health problems may have exhausted the client's physical and mental resources.
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 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." Inability to sleep, difficulty concentrating, and the client's verbalization of being overwhelmed are evidence of inability to cope. Seeking information related to the diagnosis and seeking out a spiritual adviser are positive ways of coping.
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?
The client states, "I am sure the doctors have misdiagnosed me." Denying the illness by stating a belief that the cancer diagnosis is incorrect is evidence that the client is not dealing with the illness. Inquiring about hospice and making funeral plans shows acceptance of the advanced stage of the illness. Stating a hope to attend the daughter's wedding is expressing hope for the future and is evidence of effective coping.
The nurse has identified a nursing diagnosis of "Risk for Impaired Parenting" for a client who has recently learned of being pregnant. What assessment data would be appropriate to lead the nurse to select this diagnosis?
The client states, "I do not know how to take care of a baby." It is not unusual to feel unprepared to care for a baby. However, this warrants the nurse's attention because there is an associated risk of impaired parenting. Being shocked about the pregnancy and being aware of the need to make changes in one's life are normal reactions to finding out about a pregnancy and do not necessarily indicate future problems. The nurse must work with the client about communication with family, but this does not necessarily mean that the client's parenting will be compromised.
The nurse has been providing care to a client during a divorce. The client is now divorced from the spouse, effective 2 weeks ago. The nurse identified a nursing diagnosis of "Readiness for Enhanced Coping." What statement by the client would support this nursing diagnosis?
The client states, "I feel like I can finally get along with my life now that the divorce is final." The client's statement of being able to continue with life now that the divorce is final indicates that the client views the finality of the divorce as a relief. Because the client is eager to move on, the nurse would decide that "Readiness for Enhanced Coping" would be appropriate in this case. The client's statement of disbelief, alcohol use, and financial difficulties indicate difficulty in coping with the divorce and would not provide evidence or support for this diagnosis.
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. 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.
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?
The nurse should determine the reason for the client's refusal. Before addressing the issue, the nurse must determine why the client refused the lab draw. It is essential to know the cause before planning how to address the issue. It is immaterial how long the client has been in the hospital, what laboratory tests are critical, or what the client's last results were.
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?
The parent states, "I cannot allow anyone else to help because they won't do it right." The parent's statement of not allowing anyone to help because "they won't do it right" supports the nursing diagnosis of Caregiver Role Strain. The parent's statement indicates an inability to allow help, which will cause mental and physical strain. The other statements indicate a healthy ability to use coping mechanisms to deal with this difficult situation.
What is the purpose of establishing a nursing diagnosis?
To describe a functional health problem 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?
Validate with the client that excessive food intake is the cause of the client's obesity. 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 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.
The nurse recognizes that health problems that the nurse can address by independent nursing interventions are called:
actual or potential nursing diagnoses. 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:
clustering. 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. 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 witihin 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 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. 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.
The nurse is aware that nursing diagnoses are:
within the nursing scope of practice to develop and client-focused. Nursing diagnoses are within the nursing scope of practice to develop and are client-focused. They are developed collaboratively with the client, are based on assessment data, and can change from day to day as the client's responses change. They are not do not depend on nor are they dictated by medical diagnoses, and they are not based on the input of the primary care provider.
