Unit 1 Nursing Diagnoses

Question 1

Anxiety

Answer 1

A vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with threat.

Question 2

Disturbed Body Image

Answer 2

Confusion in mental picture of one’s physical self

Question 3

Impaired Verbal Communication

Answer 3

Decreased, delayed, or absent ability to receive, process, transmit, and/or use a system of symbols

Question 4

Decisional Conflict

Answer 4

Uncertainty about course of action to be taken when choice among competing actions involves risk, loss, or challenge to values and beliefs

Question 5

Defensive Coping

Answer 5

Repeated projection of falsely positive self-evaluation based on a self-protective pattern that defends against underlying perceived threats to positive self-regard

Question 6

Ineffective Coping

Answer 6

Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources

Question 7

Ineffective Denial

Answer 7

Conscous or unconscious attempt to disavow the knowledge or meaning of an event to reduce anxiety/fear, but leading to the detriment of health

Question 8

Complicated Grieving

Answer 8

A disorder that occurs after the death of a significant other in which the experience of distress accompanying breavement fails to follow normative expectations and manifests in functional impairment

Question 9

Risk for Complicated Grieving

Answer 9

At risk for a disorder that occurs after the death of a significant other in which the experience of distress accompanying bereavement fails to follow normative expectations and manifests in functional impairment

Risk Factors:

• Death of a significant other
• Emotional Instability
• Lack of social support

Question 10

Ineffective Self Health Management

Answer 10

Inability to indentify, manage, and/or seek out help to maintain health

Question 11

Hopelessness

Answer 11

Subjective state in which individual sees limited or no alternatives or personal choices available and is unable to mobilize energy on own behalf

Question 12

Risk for Lonliness

Answer 12

At risk for experiencing discomfort associated with a desire or need for more contact with others

Risk Factors:

• Affectional deprivation
• Cathectic Deprivation
• Physical Isolation
• Social Isolation

Question 13

Noncompliance

Answer 13

Behavior of a person and/or caregiver that fails to coincide with a health-promoting or therapeutic plan agreed on by the person (and/or family and/or community) and health care professional; in the presence of an agreed-on, health-promoting, or therapeutic plan, person’s or caregiver’s behavior is fully or partially nonadherent and may lead to clinically ineffective or patirally ineffective outcomes

Question 14

Disturbed Personal Identity

Answer 14

Inability to maintain an integrated and complete perception of self

Question 15

Post Trauma Syndrome

Answer 15

Sustained maladaptive response to a traumatic, overwhelming event

Question 16

Powerlessness

Answer 16

Perception that one’s own actions will not significantly affect an outcome; a perceived lack of control over current situation or immediate happening

Question 17

Risk for Powerlessness

Answer 17

At risk for perceived lack of control over a situation and/or one’s aility to significantly affect an outcome

Question 18

Rape Trauma Syndrome

Answer 18

Sustained maladaptive response to a forced, violent, sexual penetration against the victim’s will and consent

Question 19

Impaired Individual Resilience

Answer 19

Decreased ability to sustain a pattern of positive responses to an adverse situation or crisis

Question 20

Chronic Low Self Esteem

Answer 20

Long-standing negative self-evaluating/feelings about self or self-capabilities

Question 21

Situational Low Self Esteem

Answer 21

Development of a negative perception of self-worth in response to a current situation

Question 22

Self Mutilation

Answer 22

Deliberate self-injurious behavior causing tissue damage with the intent of causing nonfatal injury to attain relief of tension

Question 23

Risk for Self Mutilation

Answer 23

At risk for diliberate self-injurious behavior causing tissue damage with the intent of causing nonfatal injury to attain relief of tension

Risk Factors (a few):

• Adolescence
• Autistic
• Battered child
• Borderline personality disorders
• Character disorders
• Childhood illness
• Childhood sexual abuse
• Childhood surgery
• Low self-esteem
• Violence between parental figures

Question 24

Disturbed Sensory Perception (specify visual, auditory, kinesthetic, gustatory, tactile, olfactory)

Answer 24

Change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or imparied response to such stimuli

Question 25

Impaired Social Interaction

Answer 25

Insufficient or excessive quantity or ineffective quality of social exchange

Question 26

Social Isolation

Answer 26

Aloneness experienced by the individual and perceived and imposed by others and as a negative or threatening state

Question 27

Chronic Sorrow

Answer 27

Cyclical, recurring, and potentially progressive pattern of pervasive sadness experienced (by caregiver, individual with chronic illness or disability) in response to continual loss throughout trajectory of an illness or disability

Question 28

Risk for Suicide

Answer 28

At risk for self-inflicted, life-threatening injury

Related Factors (some):

• Buying a gun
• Changing a will
• Giving away possessions
• H/o prior suicide attempt
• Divorced
• Male
• Widowed
• Illness
• Childhood Abuse
• Substance abuse
• Living alone
• Loss of independence
• Lonliness
• Loss of important relationship
• Social isolation
• States desire to die
• Threats of killing oneself

Question 29

Risk for Other-Directed Violence

Answer 29

At risk for behaviors in which an individual demonstrates that he or she can be physically, emotionally, and/or sexually harmful to others

Question 30

Risk for Self-Directed Violence

Answer 30

At risk for behaviors in which an individual demonstrates that he/she can be physically, emotionally, and/or sexually harmful to self