PrepU Chapter 15: Diagnosing
A client is caring for the client's mother-in-law, who is an older adult who requires assistance with performing 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." -"I feel great but wish that I could get more sleep." -"My mother-in-law and I go for a walk daily." -"My mother-in-law makes dinner on Tuesdays, and I cannot stand her cooking."
"I just don't have time to take a shower." Explanation: 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 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
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? -Readiness for Enhanced Knowledge: Childhood Immunizations -Ineffective Health Maintenance related to lack of knowledge of childhood immunizations -Risk for Infection Transmission related to lack of 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.
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.
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
Which is an accurately phrased risk nursing diagnosis? -Risk for Impaired Coping as evidenced by client crying -Risk for Fluid Volume Excess related to increased oral intake as evidenced by consuming 3 L of soda -Risk for Pain After Surgery -Risk for Falls related to altered mobility
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 statement appropriately identifies a risk nursing diagnosis for a client who is confined to bed?
Risk for Impaired Skin Integrity related to bed rest
Which statements accurately describe NANDA-I nursing diagnoses? Select all that apply. -A health promotion nursing diagnosis has four components: problem, descriptor, etiology, and defining characteristics. -A possible nursing diagnosis is a clinical judgment in transition from a specific level of wellness to a higher level. -A risk nursing diagnosis is a clinical judgment that concludes there is a likelihood of developing a problem that others in the same or similar situation may not. -A problem-focused nursing diagnosis represents a problem that has been validated by the presence of major defining characteristics. -A potential nursing diagnosis is a statement describing a suspected problem for which additional data are needed.
-A risk nursing diagnosis is a clinical judgment that concludes there is a likelihood of developing a problem that others in the same or similar situation may not. -A problem-focused nursing diagnosis represents a problem that has been validated by the presence of major defining characteristics. Explanation: NANDA-I describes three types of nursing diagnoses: problem-focused, risk, possible, and health promotion. Risk nursing diagnoses are clinical judgments that conclude that a person, family, or community is more vulnerable to develop the problem than others in the same or similar situation. Problem-focused nursing diagnoses represent problems that have been validated by the presence of major defining characteristics. The diagnostic statement for health promotion nursing diagnoses is a one-part statement that contains the label Readiness for Enhanced, followed by the desired higher-level wellness; related factors are not included. Possible (not potential) 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.
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 -Nutritional-metabolic -Coping-stress tolerance -Cognitive-perceptual
-Activity-exercise Explanation: 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.
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. -Collecting subjective and objective data -Organizing data -Analyzing data -Identifying patterns -Identifying indicators of potential dysfunction
-Analyzing data -Identifying patterns -Identifying indicators of potential dysfunction Explanation: During the diagnosis phase, the nurse analyzes collected data; identifies client strengths; identifies the client's normal functional level and indicators of actual or potential dysfunction; identifies patterns; validates the diagnosis; and formulates a diagnostic statement in relation to this synthesis. Collecting and organizing data are assessment activities.
A nurse is providing care to several clients who have undergone surgery. When reviewing their electronic health records, which information would the nurse identify as reflecting a nursing diagnosis? Select all that apply. -Disturbed Body Image -Pain -Impaired Skin Integrity -Wound Infection -Paralytic Ileus
-Disturbed Body Image -Pain -Impaired Skin Integrity Explanation: Disturbed Body Image, Pain, and Impaired Skin Integrity reflect nursing diagnoses, which are written to describe client problems or issues that nurses can treat independently. Wound Infection and Paralytic Ileus are medical diagnoses or collaborative problems involving potential complications.
Which would be an appropriate nursing diagnosis for a client with cachexia and decreased weight? -Anorexia Nervosa -Lack of Adequate Nutrition -Weight Loss -Imbalanced Nutrition: Less than Body Requirements
-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 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 -Ineffective Airway Clearance related to bronchial constriction -Noncompliance related to deficient knowledge of a new medical diagnosis -Anticipatory Grieving related to chronic illness management
-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.
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 -Independently managing 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 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.
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." -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." Explanation: 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.
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. -the problem's existence requires validation by the physician. -the main focus is on monitoring the body's pathophysiologic response. -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. 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.
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
"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
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 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
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. -Establish short- and long-term client goals. -Perform a focused assessment related to the reason for admission. -Verify the primary care provider's written orders.
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.
Which example of client care is not the responsibility of the nurse?
Confirming a medical diagnosis
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
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
Which component of a nursing diagnosis gives additional meaning to the nursing diagnosis?
Descriptors
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
A nurse is providing care to several clients who have undergone surgery. When reviewing their electronic health records, which information would the nurse identify as reflecting a nursing diagnosis? Select all that apply.
Disturbed Body Image Pain Impaired Skin Integrity
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 breast cancer -Disturbed Body Image related to loss of hair -Disturbed Body Image as evidenced by client's refusal to look at self -Disturbed Body Image as evidenced by client's negative comments
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.
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
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 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
When developing nursing diagnoses, the nurse should focus on which area?
Human responses to actual or potential health problems
When developing nursing diagnoses, the nurse should focus on which area? -Actions to be initiated for treatment -Human responses to actual or potential health problems -Pathophysiological responses occurring in body systems -Problem validation through physician collaboration
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.
When developing a nursing diagnosis for a client, which should the nurse do first?
Identify the significant data
When developing a nursing diagnosis for a client, which should the nurse do first? -Identify the significant data -Cluster the cues -Synthesize cue clusters -Validate the diagnosis
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.
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
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
The nurse is caring for a client who is postoperative day 2 after a total knee replacement. The client refuses to ambulate when the physiotherapist arrives at the unit. The client states, "It is too soon to get up and walk. I am worried my incision will tear open." The nurse correctly documents the problem-focused nursing diagnosis using which statement? -Impaired physical mobility related to anxiety as evidenced by expressed fear of postoperative complications. -Risk for anxiety related to fear of ambulating postoperatively. -Anxiety related to knowledge deficit regarding normal postoperative activities. -Risk for postoperative complications due to disturbed body image.
Impaired physical mobility related to anxiety as evidenced by expressed fear of postoperative complications. Explanation: A problem-focused nursing diagnostic statement contains three parts, sometimes referred to as "PES." P: Name of the health-related issue or problem as identified in the NANDA-I list. E: Etiology (the problem's cause). S: Signs and symptoms, also called defining characteristics. The name of the nursing diagnosis is linked to the etiology with the phrase "related to," and the signs and symptoms are identified with the phrase "as evidenced by." The client's ability to ambulate when expected postoperatively is impaired by anxiety related to fear of postoperative complications. A statement regarding an actual client problem must include what the problem is related to and what evidence the nurse has to indicate that there is a problem. The client is having actually anxiety and is not at risk for it. Beginning the statement with "at risk for" would make the statement inaccurate. The client has not demonstrated a knowledge deficit about normal postoperative activities. The barrier to ambulating is fear and anxiety. There is no evidence to indicate that the client has a disturbed body image. The nurse would have to assess further to confirm this is accurate and include this as evidence in the problem-focused statement.
The client is admitted to the surgical unit following an exploratory laparotomy. Which nursing diagnosis is the priority?
Impaired skin integrity
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?
Ineffective Airway Clearance
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
Which nursing diagnosis has the priority when caring for an older adult client with Alzheimer disease? -Impaired Physical Mobility -Risk for Injury -Self-Care Deficit -Impaired Memory
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 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."
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."
Which factor is most likely to contribute to the nurse making a diagnostic error?
The client withholds information during the client assessment.
The nurse has selected a nursing diagnosis of "Impaired Home Maintenance" for an older adult client. What assessment data would evidence this diagnosis?
The nurse observes unsafe conditions in the client's home.
What is the purpose of establishing a nursing diagnosis?
To describe a functional health problem
The nurse formulates the nursing diagnosis: Disturbed Body Image related to decreased ability to cope with surgical removal of right breast as evidenced by client refuses to look at surgical site and client statement, "I'm ugly. My husband will no longer find me desirable." The decreased ability to cope with the removal of the breast is an example of:
etiology.
What is the purpose of establishing a nursing diagnosis? -To describe a functional health problem -To collaborate with the physician -To identify medical problems -To meet accreditation criteria
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.
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
When used in a nursing diagnosis, the descriptor "impaired" has which meaning? -Weakened or damaged -Consisting of many interconnecting parts or elements -Late, slow, or postponed -Lack of proportion or relation between corresponding things
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.
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.
The nurse is aware that nursing diagnoses are:
within the nursing scope of practice to develop and client-focused.