Foundations Chapter 17 Nursing Diagnosis – Flashcards

B This is an example of a problem-focused nursing diagnosis with a related factor, based on NANDA-I diagnostic terminology. Most health promotion diagnoses do not have established related factors based on NANDA-I; their use is optional. Wellness diagnoses are not one of the types of NANDA-I diagnoses.

D A data cluster is a set of cues (i.e., the signs or symptoms gathered during assessment).

D Intestinal colitis is a medical diagnosis. The related factor in a nursing diagnostic statement is always within the domain of nursing practice and a condition that responds to nursing interventions. Nursing interventions do not change a medical diagnosis.

A This is the correct steps for making a nursing diagnosis.

C It is likely the charge nurse suspects that the student has not collected enough cues to support the diagnosis. A change in blood pressure and mental status changes are significant findings that can be attributed to fluid volume excess and other diagnoses. The recommendation of the symptom cluster by the registered nurse would allow the student to have sufficient data to confirm a deficient fluid volume.

C In this scenario the related factor is the mother's deficient knowledge. A related factor is a condition, historical factor, or etiology that gives a context for the defining characteristics, in this case the infant crying, inability to latch on to breast, and absent weight gain.

D A nursing diagnosis in a PES format includes the diagnostic label, related factor, and the defining characteristics by which the diagnosis is evidenced. The second nursing diagnosis is the correct format in the two-part format for writing a diagnosis. The first diagnosis has no related factor. The third diagnosis is an error, using a goal as a related factor.

B The more appropriate nursing diagnosis for this patient would be Risk for Impaired Skin Integrity because the patient's skin is clean and intact. A risk nursing diagnosis is appropriate because the patient has two risk factors, radiation and secretions on the skin.

A, C The related factors in diagnoses "Fatigue related to heart disease" and "Need for improved oral mucosa integrity related to inflamed mucosa" are incorrect. The related factor of a medical diagnosis (in Fatigue related to heart disease) cannot be corrected through nursing intervention. In "Need for improved oral mucosa integrity related to inflamed mucosa" there is no diagnosis, but instead a goal of care. "Risk for infection related to surgery" is incorrect; risk nursing diagnoses do not have defining characteristics or related factors because they have not occurred yet.

A, C This is an example of an error in interpretation and data collection. When making a diagnosis, the nurse must interpret data that he or she has collected by identifying and organizing relevant assessment patterns to support the presence of patient problems. In the case of the two diagnoses in this question, there can be conflicting cues. The nurse must obtain more information and recognize the cues that point to the correct diagnosis.

A, D, E When the nurse observes the patient wincing and holding his left side but does not gather additional assessment data, he or she makes a data collection error by omitting important data (i.e., pain severity). A nursing diagnosis cannot be made on basis of a single defining characteristic, as seen when the nurse identifies a diagnosis on the basis of a patient reporting difficulty sleeping. A nursing diagnosis needs to be related to a patient's response, not a medical diagnosis such as pneumonia. The nurse who measures joint range of motion after the patient reports pain is correctly validating findings. Considering conflicting clues ensures that the nurse does not make an interpretation error.

A, C, E Asking "How is your diabetic diet affecting you and your family?" "What worries you the most about having diabetes?" and "What do you believe will help you control your blood sugar?" are open-ended and allow the patient to share his values and health practices. The statements "You seem to not want to follow health guidelines. Can you explain why?" and "What do you expect from us when you do not take your insulin as instructed?" both show the nurse's bias.

A, C, E The use of nursing diagnosis creates a common language for nurses to communicate patient care needs, allows nurses to focus on the realm and scope of nursing practice, and helps to develop nursing knowledge. It is not a language for physicians and allied health staff because they do not rely on providing nursing interventions. Terminology in nursing diagnosis may be familiar to other health care providers but not in a way for directing nursing interventions. Nursing diagnosis has the purpose of creating practice guidelines for nursing.

B, D The correct diagnoses of Sleep Deprivation and Ineffective Protection are worded with related factors that will respond to nursing interventions. Nursing interventions do not change a medical diagnosis or diagnostic test. Instead nurses direct nursing interventions at behaviors or conditions that they are able to treat or manage. The first two incorrect diagnoses use a medical diagnosis and diagnostic procedure respectively as related or etiological factors. These are not conditions that nursing interventions can treat. The last diagnosis is incorrect because it is related to an assessment finding of a symptom or a defining characteristic.

2, 3, 5 Collecting, clustering, and interpreting data are common sources of errors in the nursing diagnostic process, according to NANDA-I. In the data collection process, errors sometimes occur due to a lack of knowledge or skills, inaccurate data, missing data, and disorganization. In clustering, errors may occur due to an insufficient cluster of cues, premature or early closure, and incorrect clustering. In the interpreting process, errors may occur due to inaccurate interpretation of cues, failure to consider conflicting cues, and the use of unreliable or invalid cues. Implementation and evaluation are not included in the nursing diagnostic process.

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

1, 2, 3, 5 A nurse who listens to lungs for the first time and is not sure if abnormal lung sounds are present is displaying a lack of skill, an error in collecting data. After reviewing objective data, a nurse who selects a diagnosis of fear before asking the patient to discuss her feelings is using an insufficient number of cues, which is an error in interpretation. A nurse who uses an incorrect diagnostic label is not accurately identifying the problem, which is a labeling error. A nurse who prepares to complete a decision on diagnosis and realizes that clinical criteria are grouped incorrectly to form a pattern is an example of incorrect clustering, a clustering error.

2, 4, 5 A medical diagnosis is the identification of a disease condition based on a specific evaluation of physical signs, symptoms, the patient's medical history, and the results of diagnostic tests. Osteoarthritis and diabetes mellitus are medical diagnoses, because these can be diagnosed by a healthcare provider through diagnostic tests and medical history. Medical diagnoses are based on the results of diagnostic tests. A primary healthcare provider is licensed to describe medical diagnoses and treat diseases. Acute pain is a nursing diagnosis. It can be easily identified by observing a patient's signs and symptoms and does not require any specific diagnostic test. A medical diagnosis does not include a clinical judgment about an individual and his or her family.

3 An accurate nursing diagnosis helps ensure effective and efficient nursing interventions. Selecting the correct nursing diagnosis is based on proper assessment of the patient and proper analysis of the health problem. It enhances the nursing care provided to the patient. It does not decrease the side effects of the medicines or the cost of treatment. Further assessment after the nursing diagnosis is essential to evaluate the effectiveness of the activities performed.

2 The question regarding how the health problem affects the patient and his or her family provides information regarding cultural practices followed by the family. The question regarding visiting the healthcare setting does not provide information about the cultural practices of the patient. Instead, it gives information regarding the patient's health status. The question about informed consent does not provide information regarding the patient's cultural practices. The question regarding the side effects of the medications does not reveal the cultural practices of the family. Instead, this question gives information regarding the patient's knowledge about the medications.

1, 2, 3 Inaccurate interpretation of cues, use of an insufficient number of cues, and failure to consider conflicting cues may cause interpretation errors and lead to inaccurate diagnoses. An insufficient cluster of cues does not directly cause interpretation errors but could result in errors in clustering of data. Similarly, failing to validate the nursing diagnosis with the patient does not directly cause interpretation errors but could result in a labeling error.

3, 4 The nurse assessing the edema in a patient's lower leg who is unsure how to assess the severity of edema fails to validate her assessment findings of edema, either by using a scale to measure the severity or by asking a colleague to validate her findings. The nurse who identifies a diagnosis based on a single defining characteristic prematurely closes clustering, which can lead to an inaccurate diagnosis. The nurse who listens to lung sounds after a patient reports difficulty breathing validates findings to make an accurate diagnosis. The nurse who considers conflicting cues in deciding which diagnostic label to choose interprets cue clusters to make an accurate diagnosis. In all cases the related factor or risk factor is a condition for which the nurse can implement preventative measures, not a medical diagnosis.

1, 2, 5 Accurately interpreting and using reliable cues are ways to prevent errors in interpretation while making the nursing diagnosis. The nurse should also consider the influence of culture or developmental stage on the patient's health when formulating a nursing diagnosis. Failure to consider conflicting cues and using an insufficient number of cues may lead to misinterpretation and can lead to errors.

1, 2, 4, 5 According to NANDA-I diagnoses, related factors come in four categories: situational, maturational, treatment-related, and pathophysiological. A related factor is identified from the patient's assessment data. The related factor is associated with a patient's actual response to the health problem. It can be changed by using specific nursing interventions. According to the NANDA I diagnoses, psychological is not considered a category of related factors.

2, 3, 4 The standard formal nursing diagnostic statements of the North American Nursing Diagnosis Association-International (NANDA-I) promotes the creation of practice guidelines that reflect the essence and science of nursing. They do not necessarily follow the traditional guidelines, which have been handed over through generations. The nursing diagnostic statements do not align the role of the nurse with other health care providers; rather, it distinguishes the nurse's role from that of other health care providers. Nursing diagnostic statements help nurses focus on the scope of nursing practice specifically, not medical practice as a whole. The nursing diagnostic statement essentially helps to foster the development of nursing knowledge. The nursing diagnostic statement allows nurses to communicate with each other in both written and electronic formats.

2, 3, 5, 1, 4 After the complete assessment of the patient's health status, the nurse should interpret and analyze the meaning of the data. The next step involves the nurse classifying the signs and symptoms of the patient's condition. Then, the nurse should look for defining characteristics and related factors. After this step is completed, the nurse must identify the patient's needs. The final step of the nursing diagnostic process involves formulating the nursing diagnoses and the collaborative symptoms present in the patient.

4 Inaccurate understanding of cues is a diagnostic error related to interpretation. Inaccurate data and disorganization are diagnostic errors related to data collection. Failure to seek guidance is an error related to the labeling of data.

2 Urinary stress incontinence is an actual diagnosis. An actual diagnosis describes human responses to health conditions or life processes that exist in an individual, family, or community. A nursing risk diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. A nursing health promotion diagnosis is a clinical judgment of a person's, family's, or community's motivations, desires, and readiness to increase well-being. A chronic diagnosis is not a type of nursing diagnosis.

4 A nursing diagnosis focuses on a patient'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 when formulating the nursing diagnosis. These components are part of a medical diagnosis.

3, 4, 1, 2 The initial step of the nursing diagnosis is to collect data about the patient from the patient, family, and healthcare 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 patient's response to health conditions. After reviewing all the information, the patient's specific healthcare problems are identified.

1, 3, 4 Giving satisfactory answers to the patient's questions should make the patient less anxious. Providing detailed instructions about the recovery process and the surgical procedure helps the patient become familiar with the operation and reduces anxiety. Performing range-of-motion exercises is helpful for impaired physical mobility but probably will not decrease anxiety. Providing instructions about discharge planning is unlikely to reduce the patient's anxiety.

3, 4, 5 The nurse should identify treatable etiology or risk factors, the problems caused by the treatment, and the patient's response in order to reduce errors in the diagnostic statement. Identifying a medical diagnosis does not reduce errors in the diagnostic statement. Similarly, identifying clinical signs and symptoms helps focus treatment but does not reduce diagnostic errors.

4 According to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the nurse should maintain confidentiality about the health information of the patient. Therefore, the nurse should politely tell the caregiver that accessing the patient's medical records is not in accordance with the law. There is no need to report to the primary healthcare provider because it is not an emergency situation. Ignoring the caregiver's words is not professional. The nurse should not give access to the patient's medical records unless an informed consent is obtained from the patient.

3 The PES format stands for: problem (P), etiology or related factor (E), and symptoms or defining characteristics (S). In this case, the related factor is the incisional trauma.

1 A health promotion nursing diagnosis is a type of nursing diagnosis that indicates a person's readiness to enhance specific health behaviors for well-being. A human response to health conditions that may develop in a vulnerable individual is a risk nursing diagnosis. A human response to health conditions that exist in an individual or community is an actual nursing diagnosis. A potential response to the health problem that can change by using specific nursing interventions is a related factor.

2, 4, 5 The presence of abdominal pain, distention, and a change in bowel elimination pattern forms a cluster, suggesting an elimination problem.

1 A related factor is the reason for the nursing diagnosis. A change in the related factor tends to bring about a change in the nursing diagnosis and the patient's condition. The patient has acute pain due to inflammation of the pancreas. The related factor is inflammation of the pancreas. The acute pain diagnosis would change if there were a change in the status of the related factor. Fever, distention of the abdomen, and vomiting are not the reasons for the patient's pain.

4 According to Nursing Diagnosis Association-International (NANDA-I), health promotion nursing diagnosis involves a clinical judgment concerning motivation and desire to increase well-being and actualize human health potential. The education imparted by the group is targeted at motivating and increasing the well-being of the community. A medical diagnosis is a general term that involves the identification of a condition based on a specific evaluation of physical signs and symptoms. It encompasses all kind of diagnosis. NANDA-I defines risk nursing diagnoses as a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions. Problem-focused nursing diagnoses describe a clinical judgment concerning an undesirable human response to a health condition that exists in an individual or a community.

3, 4, 5 Collaborative problems are actual or potential physiological complications that the nurse can monitor to detect the onset of changes in the patient's status. Hemorrhage, paralysis, and wound infections are collaborative problems. These problems require nursing and monitoring. Cold and nausea are not collaborative problems because they do not lead to multiple complications.

2, 3, 5 A data cluster is a set of signs or symptoms gathered during assessment and grouped together in a logical way. Respiratory rate, lung sounds, and shortness of breath are respiratory assessment findings that may be grouped together to manage a respiratory problem. Weakness and dysuria aren't directly related to respiratory issues.

3, 4 NANDA-I diagnoses have a broad literature base, and many are evidence-based. NANDA-I diagnoses are continually refined by the professional nurses, not primary health care providers. NANDA-I diagnoses have a broad literature base for the nurse's reference. NANDA-I classifications are considered one of the most comprehensive of all the nursing classifications. NANDA-I diagnoses emphasize providing accurate documentation of health problems.