Chapter 17 Vocabulary Review

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Collaborative problem
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An actual or potential physiological complication that nurses monitor to detect the onset of changes in a patients health status. Physiological complication that requires the nurse to use nursing and health care provider prescribed interventions to maximize patient outcomes.
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Data Cluster
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Set of signs or symptoms that are grouped together in logical order.
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Defining Characteristics
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The observable assessment cues that cluster as manifestations of a problem focused or health promotion nursing diagnosis. Observable assessment cues such as patient behavior and physical signs that support each problem-focused diagnostic judgement.
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Diagnostic Label
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The name of the nursing diagnosis as approved by NANDA 1. It describes the essence of a patients response to health conditions in as few words as possible.
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Health Promotion nursing diagnosis
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A clinical judgement concerning a patients motivation and desire to increase well-being and actualize human health potential. (patients relate readiness)
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medical diagnosis
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The identification of a disease condition based on a specific evaluation of physical signs and symptoms a patients medical history, and the results of diagnostic tests and procedures. Stays constant as a condition remains.
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Who is licensed to treat diseases and conditions described in medical diagnostic statements?
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Physicians and An advanced practice nurse. Note: an advanced practiced nurse does not perform surgery.
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North American Nursing Diagnosis Association International (NANDA 1)
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A list of several hundred diagnoses and continues to grow. The problems that a patient has or is at risk for based on available data describes a nursing diagnosis as a clinical judgment about individuals, family o community responses to actual or potential health problems and life processes.
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Nursing Diagnosis
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A clinical judgement concerning a human response to health conditions/life processes, or vulnerability for that response by an individual, family or community that a nurse is licensed and competent to treat.
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Problem-focused nursing diagnosis
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describes a clinical judgement concerning an undesirable human response to a health condition/life process that exists in an individual, family or community
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related factor
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Any condition or event that accompanies or is linked with the patients health care problem
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risk nursing diagnosis
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A clinical judgement concerning the vulnerability of an individual, family, group or community for developing an undesirable human response to health conditions/life processes. Lack defining characteristics or related factors since they have not occurred.
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risk factor
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environmental, physiological, psychological, genetic or chemical elements that place a person at risk for a health problem.
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etiology
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Cause of disease
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Question 1: The nurse is teaching nursing students about medical diagnoses. Which statements by the students indicate effective learning? Select all that apply. 1 “Acute pain is a medical diagnosis.” 2 “Osteoarthritis is a medical diagnosis.” 3 “A medical diagnosis includes the clinical judgment about an individual and his family.” 4 “Medical diagnoses are based on the results of diagnostic tests.” 5 “A primary healthcare provider is licensed to describe medical diagnoses
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2,4,5 2 “Osteoarthritis is a medical diagnosis.” 4 “Medical diagnoses are based on the results of diagnostic tests.” 5 “A primary healthcare provider is licensed to describe medical diagnoses
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Question 2: What is the benefit of an accurate nursing diagnosis? 1 It decreases the side effects of medications. 2 It reduces the cost of treatment to the patient. 3 It helps ensure effective and efficient nursing interventions. 4 It prevents further assessment
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3 It helps ensure effective and efficient nursing interventions.
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Question 3. The nurse is caring for a football player hospitalized for ankle surgery. The patient communicates properly during the interview. The nurse finds a quiver in the patient’s voice as he expresses his worry about not being able to play. The nurse observes that the patient has fidgety hands and legs. The nurse concludes that the patient is uncertain about his ability to play post surgery. Which data cluster helps the nurse determine anxiety is present? Select all that apply. 1 Verbal expression of worry 2 Fidgety hands and legs 3 A quiver in the patient’s voice while talking 4 Impending ankle surgery 5 Hospitalization
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1 Verbal expression of worry 2 Fidgety hands and legs 3 A quiver in the patient’s voice while talking
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Question 4. A group of nurses is organizing an educational session to teach the population of a particular community about the roots of cardiovascular disease and its impact on the human body. Which type of nursing diagnosis is being followed in this scenario? 1 Medical diagnosis 2 Risk nursing diagnosis 3 Problem-focused nursing diagnosis 4 Health promotion nursing diagnosis
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4 Health promotion nursing diagnosis
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Question 5: Which term describes data that appear to show some type of patterned relationship with a nursing diagnosis? 1 Data cluster 2 Concept map 3 Related factors 4 Defining characteristic
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3 Related factors
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Question 6: Which question does the nurse ask the patient with renal disorder while selecting nursing diagnoses relevant to the patient’s culture? 1 “How often do you visit your healthcare setting?” 2 “How does this health problem affect you and your family?” 3 “What should you know before signing an informed consent?” 4 “Do you know about the side effects of the medications that you are using?”
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2 “How does this health problem affect you and your family?”
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Question 7.: Following an assessment, the nurse is formulating a nursing diagnosis using the PES format. What does the S in PES stand for? 1 Situation 2 Symptoms 3 Sensitivity 4 Separation of data
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2 Symptoms
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Question 8. A patient is diagnosed with urinary stress incontinence. The nurse identifies it as which type of diagnosis? 1 Risk diagnosis 2 Actual diagnosis 3 Chronic diagnosis 4 Health promotion diagnosis
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2 Actual diagnosis
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Question 9 What could be the effect of an incorrect nursing diagnosis? 1 It could affect the quality of patient care. 2 It would be corrected automatically in the system. 3 It could affect the patient’s cost of treatment. 4 It could produce a psychological disorder in the patient
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1 It could affect the quality of patient care.
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Question 10. Which is an example of an interpreting error in nursing diagnostics? 1 Inaccurate data 2 Disorganization 3 Failure to seek guidance 4 Inaccurate understanding of cues
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4 Inaccurate understanding of cues
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Question 11. A patient complains of pain when swallowing solid food. The nurse asks the patient if he or she has a history of substance abuse that has caused this pain. What kind of diagnostic error is does the nurse make in this scenario? 1 Errors in data collection 2 Errors in data clustering 3 Errors in the diagnostic statement 4 Errors in interpretation and analysis of data
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1 Errors in data collection
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Question 12. Which errors may occur when the nurse makes the nursing diagnosis prior to grouping all data? 1 Errors in data clustering 2 Errors in data collection 3 Errors in the diagnostic statement 4 Errors in interpretation and analysis of data
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1 Errors in data clustering
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Question 13. Following an assessment, the nurse is formulating a nursing diagnosis using the PES format. What does the P in the acronym PES stand for? 1 Period 2 Problem 3 Prevention 4 Predication
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2 Problem
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Question 14. Which patient-related factors fall under health promotion nursing diagnosis? Select all that apply. 1 The patient follows poor hygiene measures. 2 The patient is willing to eat nutritious foods. 3 The patient shows decreased interaction with society. 4 The patient is ready to increase his or her coping skills. 5 The patient is ready to perform regular exercises
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2,4,5 2 The patient is willing to eat nutritious foods. 4 The patient is ready to increase his or her coping skills. 5 The patient is ready to perform regular exercises
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Question 15. What is a clinical judgment that concerns motivation and desire to increase well-being and actualize human health potential? 1 Medical diagnosis 2 Risk nursing diagnosis 3 Problem-focused nursing diagnosis 4 Health promotion nursing diagnosis
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4 Health promotion nursing diagnosis
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Question 16. Which errors may occur when the nurse makes the nursing diagnosis prior to grouping all data? 1 Errors in data clustering 2 Errors in data collection 3 Errors in the diagnostic statement 4 Errors in interpretation and analysis of data
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1 Errors in data clustering
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Question 17. The nurse is teaching nursing students about medical diagnoses. Which statements by the students indicate effective learning? Select all that apply. 1 “Acute pain is a medical diagnosis.” 2 “Osteoarthritis is a medical diagnosis.” 3 “A medical diagnosis includes the clinical judgment about an individual and his family.” 4 “Medical diagnoses are based on the results of diagnostic tests.” 5 “A primary healthcare provider is licensed to describe medical diagnoses.
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2,4,5 2 “Osteoarthritis is a medical diagnosis.” 4 “Medical diagnoses are based on the results of diagnostic tests.” 5 “A primary healthcare provider is licensed to describe medical diagnoses.
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Question 18. A nurse is assessing the health status of a patient. There are no additional data needed for the assessment procedure. In which order should the nurse follow the nursing diagnostic process after this stage? 1. The nurse should identify the patient needs. 2. The nurse should interpret and analyze the meaning of the data. 3. The nurse should classify signs and symptoms. 4. The nurse should formulate the nursing diagnoses and collaborative symptoms. 5. The nurse should look for defining characteristics and related factors.
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Question 19. The nurse identified that the patient has pain of 7 on a scale of 1 to 10; he winces during movement, and he expresses discomfort over the incisional area. He guards the area by resisting movement. The incision appears to be healing, but there is natural swelling. What would be the E in a three-part nursing diagnostic statement using the PES format? 1 Severe pain 2 Natural swelling 3 Related to incisional trauma 4 Wincing, guarding, restricted turning and positioning
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3 Related to incisional trauma
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Question 20. The nurse is designing a care plan for a patient admitted to the hospital with pneumonia. The nurse is using the PES format (problem, etiology, and symptom) 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 the patient must take 3 Dyspnea or difficulty in breathing 4 Problems caused by smoking 5 The diet and regimen to be followed in this disease
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1,3,4 1 Cough and shortness of breath 3 Dyspnea or difficulty in breathing 4 Problems caused by smoking
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Question 21. The nurse is preparing a diagnostic statement for a patient who has diabetes. What is the most appropriate step the nurse should take in this scenario? 1 The nurse should identify the nursing intervention, not the patient problem. 2. The nurse should identify nursing diagnoses from a cluster of defining characteristics and not just a single symptom. 3 The nurse should identify the medical diagnosis rather than the patient’s response when creating the statement. 4 The nurse should identify the treatment or the study itself, rather a problem caused by the treatment or diagnostic study
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2. The nurse should identify nursing diagnoses from a cluster of defining characteristics and not just a single symptom.
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Question 22. The nurse completed the following assessment: 63-year-old female patient has had abdominal pain for 6 days. She reports not having a bowel movement for 4 days, whereas she normally has a bowel movement every 2 to 3 days. She has not been hospitalized in the past. Her abdomen is distended. She reports being anxious about upcoming tests. Her temperature was 37° C, pulse 82 and regular, blood pressure 128/72. Which data form a cluster, showing a relevant pattern? Select all that apply. 1 Vital sign results 2 Abdominal distention 3 Age of patient 4 Change in bowel elimination pattern 5 Abdominal pain 6 No history of hospitalization
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2,4,5 2 Abdominal distention 4 Change in bowel elimination pattern 5 Abdominal pain
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Question 23. On what should the nurse focus when formulating a nursing diagnosis? 1 Disease 2 Complication 3 Physiological event 4 Potential response to a health problem
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4 Potential response to a health problem
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Question 24. A student nurse is gathering information from an elderly patient. Which of the student nurse’s actions indicates the need for further teaching? 1 Maintaining good eye contact with the patient 2 Giving more time for the patient to answer questions 3 Sitting straight in the chair while talking with the patient 4 Nodding his or her head in response to the patient’s words
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3 Sitting straight in the chair while talking with the patient
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Question 25. The nurse is teaching a group of students about the application of nursing diagnosis to care planning. Which statements indicate effective learning? Select all that apply. 1 “Nursing diagnoses direct the planning process and the selection of nursing interventions.” 2 “Nursing diagnoses are a universal means for communication between professional nurses and the public.” 3 “A nursing diagnosis would lead the primary health care provider to prescribe a low-carbohydrate diet and medication to a patient with diabetes.” 4 “Nursing diagnoses help the primary health care provider determine appropriate nursing interventions and specific outcomes.” 5 “Nursing diagnosis of damaged skin directs a nurse to apply a support surface to a patient’s bed and initiate a turning schedule.”
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1,5 1 “Nursing diagnoses direct the planning process and the selection of nursing interventions.” 5 “Nursing diagnosis of damaged skin directs a nurse to apply a support surface to a patient’s bed and initiate a turning schedule.”
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Question 26. The nurse is designing a care plan for a patient who is experiencing dyspnea. Which components of the assessment data can be part of the risk nursing diagnosis for this patient? Select all that apply. 1 Cyanosis 2 The family history of the patient 3 Impaired gaseous exchange in the lungs 4 Reduced oxygen saturation of the blood 5 The diet that the patient should follow for this disorder
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1,3,4 1 Cyanosis 3 Impaired gaseous exchange in the lungs 4 Reduced oxygen saturation of the blood
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Question 27. What is a health promotion diagnosis, according to NANDA-I? 1 It describes a person’s readiness to enhance specific health behaviors for well-being. 2 It describes human responses to health conditions that may develop in a vulnerable individual. 3 It describes human responses to health conditions that exist in an individual or community. 4 It is associated with a potential response to the health problem and can change by using specific nursing interventions
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1 It describes a person’s readiness to enhance specific health behaviors for well-being.
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Question 28. Which steps are essential for decision making in a diagnostic process? Select all that apply. 1 Data clustering 2 Risk nursing diagnosis 3 Formulating the diagnosis 4 Identifying patient health problems 5 Health promotion nursing diagnosis
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1,3,4 1 Data clustering 3 Formulating the diagnosis 4 Identifying patient health problems
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Question 29 In the examples given, which nurses are making nursing diagnostic errors? Select all that apply. 1 The nurse who listens to lung sounds after a patient reports difficulty breathing 2 The nurse who considers conflicting cues in deciding which diagnostic label to choose 3 The nurse who is assessing the edema in a patient’s lower leg and is unsure how to assess the severity of edema 4 The nurse who identifies a diagnosis based on a single defining characteristic 5 The nurse who identifies a risk-for diagnosis related to a medical diagnosis
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3,4 3 The nurse who is assessing the edema in a patient’s lower leg and is unsure how to assess the severity of edema 4 The nurse who identifies a diagnosis based on a single defining characteristic
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Question 30 The nurse is identifying the related factors by studying a patient’s assessment data. According to NANDA-I diagnoses, under which categories should the nurse classify the related factors? Select all that apply. 1 Situational 2 Maturational 3 Psychological 4 Treatment-related 5 Pathophysiological
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1,2,4,5 1 Situational 2 Maturational 4 Treatment-related 5 Pathophysiological
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Question 31 In the given examples, which nurses are making nursing diagnostic errors? Select all that apply. 1 A nurse listens to lungs for the first time and is not sure if abnormal lung sounds are present. 2 After reviewing objective data, a nurse selects a diagnosis of fear before asking the patient to discuss her feelings. 3 A nurse uses an incorrect diagnostic label. 4 A nurse considers a patient’s cultural background when reviewing cues. 5 A nurse prepares to complete a decision on diagnosis and realizes that clinical criteria are grouped incorrectly to form a pattern
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1,2,3,5 1 A nurse listens to lungs for the first time and is not sure if abnormal lung sounds are present. 2 After reviewing objective data, a nurse selects a diagnosis of fear before asking the patient to discuss her feelings. 3 A nurse uses an incorrect diagnostic label. 5 A nurse prepares to complete a decision on diagnosis and realizes that clinical criteria are grouped incorrectly to form a pattern
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Question 32 The nurse is attending to a patient in a coronary care unit. She is revising the care plan after evaluating the patient outcomes. Which steps of the nursing processes is the nurse performing? Select all that apply. 1 Assessment 2 Evaluation 3 Implementation 4 Planning 5 Diagnosis
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1,2 1 Assessment 2 Evaluation
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Question 33 A patient is anxious about an operation scheduled for the next day. The nurse identifies that the patient is anxious. Which interventions does the nurse use to decrease the patient’s anxiety related to surgery? Select all that apply. 1 Provide satisfactory answers to the patient’s questions. 2 Instruct the patient to perform range-of-motion exercises. 3 Provide detailed instructions about the recovery process. 4 Provide detailed instructions about the surgical procedure. 5 Provide detailed instructions about discharge planning
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1,3,4 1 Provide satisfactory answers to the patient’s questions. 3 Provide detailed instructions about the recovery process. 4 Provide detailed instructions about the surgical procedure.
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Question 34 Which diagnostic error may lead to an error in nursing diagnosis? Select all that apply. 1 Failure to seek guidance when the nurse has doubts 2 Premature or early closure of clustering 3 Selection of the wrong diagnostic label 4 Failure to consider conflicting cues 5 Validation of nursing diagnosis with patient
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1,2,3 ******** Box 17-4 1 Failure to seek guidance when the nurse has doubts 2 Premature or early closure of clustering 3 Selection of the wrong diagnostic label
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Question 35 The nurse is assigned to a new patient admitted to the nursing unit following admission through the emergency department. The nurse collects a nursing history and interviews the patient. Place the following steps in the correct order for making a nursing diagnosis. 1. Considers context of patient’s health problem and selects a related factor 2. Reviews assessment data, noting objective and subjective clinical criteria 3.Clusters clinical criteria that form a pattern 4.Chooses diagnostic label
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2, 3, 4, 1 2. Reviews assessment data, noting objective and subjective clinical criteria 3. Clusters clinical criteria that form a pattern 4. Chooses diagnostic label 1. Considers context of patient’s health problem and selects a related factor
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Question 36 Which type of interpretation errors may occur with a nursing diagnosis? Select all that apply. 1 Inaccurate interpretation of cues 2 Use of an insufficient number of cues 3 Failure to consider conflicting cues 4 Failure to validate the nursing diagnosis with the patient 5 Insufficient cluster of cues
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1,2,3 1 Inaccurate interpretation of cues 2 Use of an insufficient number of cues 3 Failure to consider conflicting cues
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Quest
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Question 38 According to the NANDA International, what are the categories of sources of error that may occur in the nursing diagnostic process? Select all that apply. 1 Implementing 2 Collecting 3 Clustering 4 Evaluating 5 Interpreting
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2,3,5 2 Collecting 3 Clustering 5 Interpreting
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Question 39 What points should the nurse keep in mind when formulating the nursing diagnosis? Select all that apply. 1 Accurately selecting the diagnoses 2 Identifying related factors pertinent to the diagnosis 3 Selecting interventions suited for treating the diagnosed condition 4 Identifying defining characteristics of the diagnosis 5 Properly making medical diagnoses
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1,2,3,4 1 Accurately selecting the diagnoses 2 Identifying related factors pertinent to the diagnosis 3 Selecting interventions suited for treating the diagnosed condition 4 Identifying defining characteristics of the diagnosis
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Question 40 Inaccurate data collection is a source of error in diagnosis. What factors can cause errors in data collection? Select all that apply. 1 Missing data 2 Inaccurate data 3 Disorganization 4 Lack of knowledge or skill 5 Premature or early closure of clustering
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1,2,3,4 1 Missing data 2 Inaccurate data 3 Disorganization 4 Lack of knowledge or skill

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