ch 13 diagnosing – Flashcards
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Which of the following is classified as a nursing diagnosis?
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Grieving
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A client who has to undergo a parathyroidectomy is worried that he may have to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan?
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Disturbed body image related to the incision scar
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A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling makes his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client's concern?
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Disturbed body image
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A client with HIV has been admitted to a health care facility. Which of the following nursing diagnoses should be of the highest priority, keeping in mind the client's condition?
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Risk for infection
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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?
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Actual
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Which of the following reflect the diagnosis stage? Select all that apply.
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"Based on what you have told me, it seems that urinary incontinence is a problem for you. What do you think?" • The nurse identifies that the client has effectively coped with health stressors in the past. • The nurse identifies that the client who is on strict bed rest is at risk for impaired skin integrity. Explanation:
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The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this patient is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping?
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Wellness Diagnosis
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Which of the following statements appropriately identifies an at-risk nursing diagnosis for a 78-year-old woman who is confined to bed?
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Risk for impaired skin integrity related to bed rest
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The nursing diagnosis taxonomy provides nursing with
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Common language
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The act of analyzing and synthesizing cues requires
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critical thinking
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A nurse who is caring for a client admitted to the nursing unit with acute abdominal pain formulates the care plan for the client. Which of the following nursing diagnoses is the highest priority for this client?
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Impaired comfort
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A nurse sees the client grimace and documents that the client is in pain, without interviewing the client to obtain further cues. The nurse has
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A lack of cues or premature closure
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A nurse is justified in independently identifying and documenting which of the following diagnoses related to impaired elimination?
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Bowel Incontinence
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Why is coding important when writing a nursing diagnosis?
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Allows for direct reimbursement for nurses
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What association meets every 2 years to further progress in defining, classifying, and describing nursing diagnoses?
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The North American Nursing Diagnosis Association (NANDA)
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In the development of a nursing diagnosis for a client who has cachexia and decreased weight, what would be an appropriate nursing diagnosis?
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Imbalanced nutrition: less than body requirements
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Nursing diagnoses that require physician-prescribed and nurse-prescribed actions would be
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Collaborative health problems
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The nurse makes a diagnostic error when the:
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client withholds information during the nursing assessment.
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A nurse is caring for an elderly client who is scheduled for a cystoscopy the next day to determine the cause of an over-distended bladder. The client informs the nurse that this the first time that she has been admitted to a healthcare facility for an illness. Which of the following is a diagnostic label the nurse would use to formulate the nursing diagnosis?
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Anxiety
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What gives additional meaning to a nursing diagnosis?
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Descriptors
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A patient with a new colostomy often becomes short and sarcastic when nurses attempt to teach him about the management of his new appliance. The nurse has consequently documented "Noncompliance related hostility" on the patient's chart. What mistake has the nurse made when choosing and documenting this nursing diagnosis?
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Presuming to know the factors contributing to the problem
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A client is brought to the Emergency Room in an unconscious condition, accompanied by his son. The client is having respiratory arrest and is put on a ventilator. What is the most appropriate nursing diagnosis in the client?
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Impaired spontaneous ventilation
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When caring for a client, the nurse identifies and analyzes data to identify nursing diagnoses and collaborative problems. Which of the following is an important role of the nurse when caring for a client with collaborative problems?
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Reporting trends that suggest development of complications
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An elderly female patient's venous ulcer has become foul-smelling after she began using strips of a sheet to dress the wound when she ran out of sterile dressing supplies. How should the nurse document a nursing diagnosis statement related to this patient's circumstances?
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Risk for infection related to knowledge deficit"
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A nurse is reviewing the plan of care for a client with a breathing problem. Which of the following would the nurse most likely expect to identify as a relevant nursing diagnostic statement for this client?
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Ineffective airway clearance
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An example of a nursing diagnosis from the Perception/Cognition domain is:
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Impaired Verbal Communication.
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After teaching a group of students about the different types of nursing diagnoses, the instructor determines that the teaching was successful when the students identify wellness diagnoses statements as consisting of how many parts?
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1
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The nurse formulates the nursing diagnosis: Disturbed Body Image related to decreased ability to cope with surgical removal of right breast AEB 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 which of the following?
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Etiology
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Which of the following provides the nurse with the most reliable basis on which to choose a nursing diagnosis?
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A cluster of several significant cues of data that suggest a particular health problem
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Which activities does the nurse perform during the diagnosing stage? Select all that apply.
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Identifies factors contributing to the client's health problem. • Prioritizes the client's health problems with input from the client. • Validates the identified health problems with the clients.
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Which of the following errors has the nurse made in formulating the nursing diagnosis: Pain related to nurse failing to administer pain med in a timely manner AEB client pain rating of 7 out of 10, client guarding abdominal incision, client ambulates slowly.
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Used legally inadvisable terms
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According to Maslow's hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure?
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Risk for body image disturbance
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A nurse is caring for a client diagnosed with arthritis who is experiencing pain that is interfering with her ability to ambulate. The nurse accurately documents which of the following as a nursing diagnosis in the client's records?
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Impaired physical mobility related to pain
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A nursing instructor is describing the components of an actual nursing diagnosis. Which of the following would the instructor include as a characteristic feature of diagnostic labels?
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Describes the essence of the problem using as few words as possible
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What is meant by impaired state of equilibrium?
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It describes the client's condition
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A postoperative client experiences hemorrhage. The nurse understands that hemorrhage is a collaborative problem based on an understanding that this problem involves which of the following?
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A result of disease, trauma, treatment, or diagnostic studies
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Which of the following nursing diagnoses is written incorrectly as a result of the health problem and etiology being reversed?
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Prolonged Immobility related to impaired skin integrity AEB one-inch diameter open area on right buttocks surrounded by a one-inch margin of redness; wound surface clean and beefy red; no drainage or foul odor detected.
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An experienced obstetrical nurse is collecting data on a patient in labor. What is the best approach for the development of nursing diagnoses for this patient?
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Develop nursing diagnoses from clusters of significant data.
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A client who is scheduled for coronary angioplasty is concerned if the surgery is safe and wonders whether it would be beneficial to him. Which of the following nursing diagnoses relates to this client's condition?
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Risk related to unknown outcome of surgery
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What is the process of gathering and clustering data to draw inferences and propose a diagnosis?
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Diagnostic reasoning
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A client with HIV has been admitted to a health care facility. Which of the following nursing diagnoses should be of the highest priority, keeping in mind the client's condition?
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Risk for infection
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Nursing diagnoses that require physician-prescribed and nurse-prescribed actions would be
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Collaborative health problems
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After assessing a client, the nurse formulates several nursing diagnoses. Which of the following would the nurse identify as an actual nursing diagnosis?
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Impaired urinary elimination
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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?
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Actual
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The nurse is examining the assessment data of a client and diagnoses a problem of impaired tissue perfusion based on the following assessment data cues: left foot cool and pale with capillary refill > 3 seconds, diminished dorsalis pedis and posterior tibial pulses, client complaint of cramping pain in left foot. The nurse is:
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Clustering significant data cues.
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The nurse has identified a number of risk nursing diagnoses in the care of an adolescent who has been admitted to the hospital for treatment of an eating disorder. These risk diagnoses indicate which of the following?
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The patient is more vulnerable to certain problems than other individuals would be.
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Why is coding important when writing a nursing diagnosis?
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Allows for direct reimbursement for nurses
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The nurse is providing care for a patient who experienced an ischemic stroke 5 days ago. Which of the following diagnoses would the nurse be justified in identifying and documenting in the care of this patient? Select all that apply.
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• Bowel Incontinence • Impaired Swallowing • Impaired Physical Mobility
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A nurse is caring for an elderly client who is scheduled for a cystoscopy the next day to determine the cause of an over-distended bladder. The client informs the nurse that this the first time that she has been admitted to a healthcare facility for an illness. Which of the following is a diagnostic label the nurse would use to formulate the nursing diagnosis?
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Anxiety
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A 67-year-old man's right lower quadrant pain has been diagnosed as appendicitis and subsequently treated by open appendectomy. How should the nurse document a potential complication related to this patient's diagnosis and treatment?
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"PC: Atelectasis related to surgery"
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A nurse is caring for a patient admitted with dehydration after completing a triathlon in a hot, dry climate. The nurse identifies an appropriate nursing diagnosis for this patient as "Deficient fluid volume related to insufficient fluid intake as evidenced by blood pressure 84/46, heart rate 145, concentrated urine, and patient stating that he drank 200 mL of water during the 4-hour event." Identify the problem statement in this nursing diagnosis.
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Deficient fluid volume
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A nurse is educating a client about care to be taken in nephrotic syndrome. The client expresses that the teachings are of no use because the disease is not curable. What nursing diagnosis should the nurse write with regard to the client's concern?
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Risk for powerlessness
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A nurse is interviewing an asthmatic client who has a high respiratory rate and is having difficulty breathing. What appropriate nursing diagnosis should the nurse document?
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Impaired verbal communication related to the breathing problem
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A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling makes his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client's concern?
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Disturbed body image
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Which of the following best defines nursing diagnoses?
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Identification of patient problems that nurses can treat independently
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What association meets every 2 years to further progress in defining, classifying, and describing nursing diagnoses?
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The North American Nursing Diagnosis Association (NANDA)
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What gives additional meaning to a nursing diagnosis?
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Descriptors
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Which of the following reflects the diagnosis phase?
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The nurse identifies that the client does not tolerate activity.
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Which of the following is a correct guideline to follow when composing a nursing diagnosis statement?
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Place defining characteristics after the etiology and link them by the phrase "as evidenced by."
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Which of the following statements appropriately identifies an at-risk nursing diagnosis for a 78-year-old woman who is confined to bed?
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Risk for impaired skin integrity related to bed rest
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A nurse who is caring for an unresponsive client formulates the nursing diagnosis, "Risk for Aspiration related to reduced level of consciousness." The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis?
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Is written as a two-part statement
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A male patient's poorly controlled type 1 diabetes has resulted in a recent below-the-knee amputation. The home healthcare nurse that performs the patient's follow-up dressing changes has noted that the patient's apartment is in an increasing state of disarray in recent weeks. The patient attributes this to fact that he has "an awful time just getting around." Which of the following nursing diagnosis statements is most appropriate?
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Impaired Home Maintenance related to mobility alterations
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The process of nursing diagnosis carries legal implications for nurses. Which of the following legal responsibilities exists for a nurse who has documented a nursing diagnosis related to a patient's kidney failure?
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Reporting signs and symptoms related to the patient's kidney failure
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In the development and documentation of a nursing diagnosis, the nurse should follow which of the following guidelines?
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Accepted terms for nursing diagnoses may vary according to a school, employer, or specialty organization.
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A client is admitted to a psychiatric treatment unit with psychosis. Which of the following is the highest priority diagnosis for this client?
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Disturbed thought process in client
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Which of the following is an example of a nursing diagnosis?
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Constipation
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Which of the following nursing diagnoses has the highest priority when caring for an elderly client with Alzheimer's disease?
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Risk for injury
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A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues provides organization or
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Clustering
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A group of nursing students are reviewing information about nursing diagnoses. The students demonstrate understanding when they identify which of the following as a characteristic feature?
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Describes the client's response to the disease process
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In planning the care for a patient who has pneumonia, the nurse collects data and develops nursing diagnoses. Which of the following is an example of a properly developed nursing diagnosis?
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Ineffective airway clearance related to inability to clear secretions
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The nurse has drafted a nursing diagnosis of Imbalanced Nutrition: More Than Body Requirements in the care of moderately obese patient. How should the nurse proceed after writing this diagnosis?
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Validate the nursing diagnosis
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What information provides the nurse with accuracy when developing a nursing diagnosis?
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A set of clinical cues
