Quiz: Chapter 17 Nursing Diagnosis

A client is diagnosed with urinary stress incontinence. The nurse identifies it as which type of diagnosis?

Urinary stress incontinence is an actual diagnosis. Actual diagnosis describes human responses to health conditions or life processes that exist in an individual, family, or community. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. A health promotion nursing diagnosis is a clinical judgment of a person's, family's, or community's motivation, desire, and readiness to increase well-being. Chronic diagnosis is not a type of nursing diagnosis. Text Reference - p. 227

A nurse is designing a care plan for a client admitted to the hospital with pneumonia. The nurse is using the Problem, Etiology, and Symptom (PES) format for formulating nursing diagnoses. Which components can the nurse include in this PES format? Select all that apply. 1 Cough and shortness of breath 2 Medications that he has to take 3 Dyspnea or difficulty in breathing 4 Problems caused by smoking 5 The diet and regimen to be followed in this disease

1 Cough and shortness of breath 3 Dyspnea or difficulty in breathing 4 Problems caused by smoking The cough, shortness of breath, and dyspnea or difficulty in breathing constitute the problem and symptoms seen in the client. "Problems caused by smoking" gives the etiology of the disease. Medications that the person has to take and diet and regimen are not part of the PES approach. Text Reference - p. 229

The nurse formulates several nursing diagnoses after the initial data collection and assessing the client. Which components of a nursing diagnosis are diagnostic labels? Select all that apply. 1 Impaired physical mobility 2 Acute incisional pain 3 Delayed motor response 4 Musculoskeletal injury 5 Impaired sensory perception

1 Impaired physical mobility 3 Delayed motor response 5 Impaired sensory perception The diagnostic label describes the essence of a client's response to health conditions in as few words as possible. These labels include descriptors that are used to give additional meaning to the diagnosis. Examples include terms such as impaired and delayed. Therefore, impaired physical mobility, delayed motor response and impaired sensory perception are diagnostic labels. Acute incisional pain and musculoskeletal injury are related factors. Text Reference - p. 228

What should the nurse focus on when formulating a nursing diagnosis? 1 Disease 2 Complication 3 Physiological event 4 Potential response to a health problem

4 Potential response to a health problem A nursing diagnosis focuses on a client's potential response to a health problem. A nursing diagnosis provides a basis for selecting, planning, and implementing interventions. Diseases, complications, and physiological events are not the focus of formulating the nursing diagnosis. These components are part of a medical diagnosis. Text Reference - p. 227

The nurse in a geriatric clinic collects the following information from an 82-year-old client and her daughter, the family caregiver. The daughter explains that the client is "always getting lost." The client sits in the chair but gets up frequently and paces back and forth in the examination room. The daughter says, "I just don't know what to do because I worry she will fall or hurt herself." The daughter states that, when she took her mother to the store, they became separated, and the mother couldn't find the front entrance. The daughter works part time and has no one to help watch her mother. Which of the data form a cluster, showing a relevant pattern? Select all that apply. 1 Daughter's concern of mother's risk for injury 2 Pacing 3 Client getting lost easily 4 Daughter working part time 5 Getting up frequently

2 Pacing 3 Client getting lost easily 5 Getting up frequently Pacing, getting lost, and hyperactivity are a cluster of defining characteristics that point to the diagnostic label of wandering. Text Reference - p. 226

Two nurses are having a discussion at the nurses' station. One nurse is a new graduate who added, "Client needs improved bowel function related to constipation" to a client's care plan. The nurse's colleague, the charge nurse says, "I think your diagnosis is possibly worded incorrectly. Let's go over it together." A correctly worded diagnostic statement is: 1 Need for improved bowel function related to change in diet. 2 Client needs improved bowel function related to alteration in elimination. 3 Constipation related to inadequate fluid intake. 4 Constipation related to hard infrequent stools.

3 Constipation related to inadequate fluid intake. "Constipation related to inadequate fluid intake" is an accurate NANDA-I approved nursing diagnosis with an appropriate etiology. "Need for improved bowel function related to change in diet" is a goal with an etiologic factor." Client needs improved bowel function related to alteration in elimination" is a goal with a diagnostic statement. "Constipation related to hard infrequent stools" is a nursing diagnostic label with a clinical sign. Text Reference - p. 225

Which steps are considered essential by the nurse for decision making in a diagnostic process? Select all that apply. 1 Data clustering 2 Risk nursing diagnosis 3 Formulating the diagnosis 4 Identifying client health problems 5 Health promotion nursing diagnosis

1 Data clustering 3 Formulating the diagnosis 4 Identifying client health problems Data clustering, formulating the diagnosis, and identifying client health problems are the decision-making steps in a diagnostic process. In data clustering, a set of signs or symptoms is gathered during assessment, and the nurse groups the data in a logical way. Formulating a diagnosis involves reviewing all the information. A client's health problem is identified by the signs and symptoms of the disease. Risk nursing diagnosis and health promotion nursing diagnosis are types of diagnoses. Text Reference - p. 224

As per Yura and Walsh, what are the components of the nursing process? Select all that apply. 1 Planning 2 Evaluation 3 Assessment 4 Implementation 5 Nursing diagnosis

1 Planning 2 Evaluation 3 Assessment 4 Implementation 5 Nursing diagnosis As per Yura and Walsh there are four components to the nursing process. They are assessment, planning, implementation, and evaluation. Nursing diagnosis is a part of the nursing process according to most other theorists, but Yura and Walsh do not consider it part of the nursing process. Text Reference - p. 223

A nurse observes that a client has impaired urinary elimination. What factors could be responsible for this? Select all that apply. 1 Renal calculi 2 Maturational crisis 3 Urinary tract infection 4 Change in economic status 5 Change in environment status

1 Renal calculi 3 Urinary tract infection Anatomical obstructions of the urinary tract, such as renal calculi, and urinary tract infections are factors associated with impaired urinary elimination. Maturational crisis refers to a psychological imbalance in a person going through a transitional period. This factor is not related to impaired urinary elimination. Changes in economic status or environment status do not relate to urinary elimination. Text Reference - p. 229

The following nursing diagnoses all apply to one client. As the nurse adds these diagnoses to the care plan, which diagnosis will not include defining characteristics? 1 Risk for aspiration 2 Acute confusion 3 Readiness for enhanced coping 4 Sedentary lifestyle

1 Risk for aspiration A risk diagnosis does not have defining characteristics, but instead risk factors. Risk factors are the environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem. Test-Taking Tip: Reread the question if the answers do not seem to make sense, because you may have missed words such as not or except in the statement.

The nurse is assessing a client's data for the related factor of the nursing diagnosis. Which statements are true regarding the related factor? Select all that apply. 1 The related factor is within the domain of nursing practice. 2 The related factor does not always respond to nursing interventions. 3 In the case of a risk nursing diagnosis, the risk factor is the related factor. 4 The related factor is not associated with the client's actual response to a health problem. 5 The related factor is identified from the client's assessment data.

1 The related factor is within the domain of nursing practice. 3 In the case of a risk nursing diagnosis, the risk factor is the related factor. 5 The related factor is identified from the client's assessment data. The etiology or related factor of a nursing diagnosis is always within the domain of nursing practice. In the case of a risk nursing diagnosis, the risk factor is the related factor. The related factors are usually identified from the assessment data obtained from the client. It is a condition that responds to nursing interventions. The related factor is associated with a client's actual or potential response to the health problem.

A nurse is assessing a client who has asthma. How would the nurse arrange the steps in the correct sequence for making a nursing diagnosis? 1. Assessing of patient's health status 2. Data clustering 3. Selecting the diagnostic label 4. Validating data with other sources

1. Assessing of patient's health status 2. Validating data with other sources 3. Data clustering 4. Selecting the diagnostic label The initial step of the nursing diagnosis is collect data about the client from the patient, family, and health care resources. After the data has been collected and validated, then interpretation and analysis may occur. In data clustering, all the signs and symptoms are grouped in a logical way. The diagnostic label describes the essence of a client's response to health conditions. After reviewing all the information, the client's specific healthcare problems are identified. Text Reference - p. 224

A nurse is designing a care plan for a client who is experiencing dyspnea. Which components of the assessment data can be part of the risk nursing diagnosis for this client? Select all that apply. 1. Cyanosis 2. The family history of the client 3. Impaired gaseous exchange in the lungs 4. Reduced oxygen saturation of the blood 5. The diet that the client should take in this disorder

1. Cyanosis 3. Impaired gaseous exchange in the lungs 4. Reduced oxygen saturation of the blood A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. Cyanosis, impaired gas exchange, and reduced oxygen saturation of blood (hypoxia) are risk nursing diagnoses for dyspnea. The family history of the client and the diet that the client should follow during the disease are not included in the risk nursing diagnosis. Text Reference - p. 228

A nurse is caring for a football player scheduled for ankle surgery. The client communicates properly during the interview. The nurse finds a quiver in the client's voice as he expresses his worry about not being able to play. The nurse observes that the client has fidgety hands and legs. The nurse concludes that the client is uncertain about his ability to play postsurgery. What interventions should the nurse implement to reduce anxiety in the client? Select all that apply. 1. Explain the recovery process to the client. 2. Provide detailed instruction about the surgery. 3. Consult with a psychologist regarding the client's behavior. 4. Teach postoperative care to the client and his caregiver. 5. Encourage health promotion activities such as exercise and routine social activities.

1. Explain the recovery process to the client. 2. Provide detailed instruction about the surgery. 4. Teach postoperative care to the client and his caregiver. Explaining the recovery process and the surgery may reduce the client's uncertainties regarding the recovery. Teaching postoperative care to the client and caregiver makes him more self-reliant and may speed his recovery. The client's anxiety is not pathological; therefore, consulting with a psychologist at this stage is not advisable. Health promotion activities should be encouraged postoperatively. Text Reference - p. 229