17. Analysis and nursing diagnosis

Question 1

Collaborative problem

Answer 1

Physiological complication that requires the nurse to use nursing- and health care provider–prescribed interventions to maximize patient outcomes.

Question 2

Data cluster

Answer 2

Set of signs or symptoms that are grouped together in logical order.

Question 3

International Classification for Nursing Practice (ICNP®)

Answer 3

A standard terminology system used across the world, which was developed by the International Council of Nurses. The ICN is a federation of more than 130 national nurses’ associations (NNAs), representing more than 20 million nurses worldwide.

Question 4

Medical diagnosis

Answer 4

Formal statement of the disease entity or illness made by the physician or health care provider.

Question 5

NANDA International (NANDA-I)

Answer 5

North American Nursing Diagnosis Association, organized in 1973. It formally identifies, develops, and classifies nursing diagnoses.

Question 6

Nursing diagnosis

Answer 6

Formal statement of an actual or potential health problem that nurses can legally and independently treat; the second step of the nursing process, during which the patient’s actual and potential unhealthy responses to an illness or condition are identified.

Question 7

Risk nursing diagnosis

Answer 7

A clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes.

Question 8

A nurse conducts an assessment of a 42-year-old woman at a health clinic. The woman is married and lives in an apartment with her husband. She reports having frequent voiding and pain when she passes urine. The nurse asks whether she has to go to the bathroom at night, and the patient responds, “Yes.” The patient had an episode of diarrhea 1 week ago. She weighs 136 kg (300 lb). The nurse documents the assessment findings listed below. Which of the assessment findings require priority follow-up by the nurse? (Select all that apply.)

1. The patient has no history of chronic disease.
2. Patient urinates at night.
3. Patient reports having difficulty cleansing herself after voiding or passing stool.
4. Body temperature 38°C (100.4°F)
5. Recent history of weight gain
6. Knowledge of perineal care
7. Last normal bowel movement 2 days ago
8. Frequency of diarrhea

Answer 8

2. Patient urinates at night.
3. Patient reports having difficulty cleansing herself after voiding or passing stool.
4. Body temperature 38°C (100.4°F)
5. Recent history of weight gain
6. Knowledge of perineal care
7. Frequency of diarrhea

Question 9

A nurse’s assessment reveals a patient having frequent voiding and pain when she urinates. Her body temperature is 38°C (100.4°F). The nurse asks whether she has to go to the bathroom at night, and the patient responds, “Yes.” When asked how often, the patient replies, “About three times a night.” The nurse asks if having to urinate at night is recent or normal for the patient. The patient explains, “I usually go once a night but that is all.” The nurse then asks, “When you feel the need to go, can you reach the toilet in time?” The patient says, “Oh, yes, I can.” The nurse asks, “And have you had any leaking of urine?” The patient denies leaking. When asked if she is having any back or abdominal pain, the patient denies discomfort. The nurse then gathers a urine specimen from the patient and inspects its character, noting it is cloudy and foul smelling. Which of the following nursing diagnoses are indicated by cues in this patient’s assessment?

1. Impaired Kidney Function
2. Impaired Urination
3. Urge Incontinence of Urine
4. Total Urinary Incontinence

Answer 9

2. Impaired Urination

Question 10

A nurse assesses a 42-year-old woman at a health clinic. The woman is married and lives in a condo with her husband. She reports having frequent voiding and pain when she urinates. The nurse asks whether she has to go to the bathroom at night, and the patient responds, “Yes, usually twice or more.” The patient had an episode of diarrhea 1 week ago. She weighs 136 kg (300 lb) and reports having difficulty cleansing herself after voiding or passing stool. Which of the following demonstrate assessment findings that cluster to indicate the nursing diagnosis Impaired Urination. (Select all that apply.)

1. Age 42
2. Dysuria
3. Difficulty performing perineal hygiene
4. Nocturia
5. Episode of diarrhea
6. Weighs 136 kg (300 lb)
7. Frequent voiding

Answer 10

2. Dysuria
3. Nocturia
4. Frequent voiding

Question 11

A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment to the abdomen, has liquid stool, and the skin is clean and intact. The student selects the nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student has made a diagnostic error for which of the following reasons?

1. Incorrect clustering of data
2. Wrong diagnosis
3. Condition is a collaborative problem
4. Premature ending assessment

Answer 11

2. Wrong diagnosis

Question 12

Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.)

1. Offer frequent skin care because of Impaired Skin Integrity
2. Risk for Infection
3. Chronic Pain related to osteoarthritis evidenced by reduced hip range of motion
4. Activity Intolerance related to physical deconditioning evidenced by exertional dyspnea
5. Lack of Knowledge related to laser surgery

Answer 12

2. Risk for Infection
3. Activity Intolerance related to physical deconditioning evidenced by exertional dyspnea

Question 13

A nurse is assigned to a new patient admitted to the medical unit. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order.

1. Consider the context of patient’s health problem and select a related factor.
2. Review assessment findings, noting objective and subjective clinical cues.
3. Cluster cues that form a pattern.
4. Gather thorough patient data about the patient’s health problem.
5. Identify the nursing diagnosis.
6. Consider whether data are expected or unexpected based on the patient’s problem.

Answer 13

4. Gather thorough patient data about the patient’s health problem.
5. Review assessment findings, noting objective and subjective clinical cues.
6. Cluster cues that form a pattern.
7. Consider whether data are expected or unexpected based on the patient’s problem.
8. Consider the context of patient’s health problem and select a related factor.
9. Identify the nursing diagnosis.

Question 14

A nurse interviews and conducts a physical examination of a patient that includes the following findings: reduced range of motion of lower hip, reduced strength in left leg, and difficulty turning in bed without assistance. This data set is an example of:

1. Collaborative data set.
2. Diagnostic label.
3. Related factors.
4. Data cluster.
5. Validated data set

Answer 14

4. Data cluster.

Question 15

A nurse reviews data gathered regarding a patient’s response to a diagnosis of cancer. The nurse notes that the patient is restless, avoids eye contact, has increased blood pressure, and expresses a sense of helplessness. The nurse compares the pattern of assessment findings for Anxiety with those of Fear and selects Anxiety as the correct diagnosis. This is an example of the nurse avoiding an error in which of the following? (Select all that apply.)

1. Data collection
2. Data clustering
3. Data interpretation
4. Making a diagnostic statement
5. Outcome setting

Answer 15

2. Data clustering
3. Data interpretation
4. Making a diagnostic statement