Ch. 7

Question 1

Taxonomy

Answer 1

Unified language classification system.

Effective vehicle for communicating among nurses and other pros

Question 2

The clustered supporting data should

Answer 2

Reflect a readiness to address positive lifestyle changes and increase healthy behaviors.

Question 3

Diagnosis label

Answer 3

Concise term or phrase that represents a pattern of related, clustered data.
First section of every nursing diagnosis.
Describes the diagnostic focus and requires nursing judgment before its assignment to the patient

Question 4

Related factors

Answer 4

Underlying cause or etiology of patients problem

Question 5

Risk factors

Answer 5

Environmental, physical, psychological or situational concerns that increase a patients vulnerability to a potential problem or concern.
Second part of nursing diagnosis

Question 6

Defining characteristics

Answer 6

Third part of ACTUAL diagnosis.
Second of HEALTH-PROMOTION diagnosis.
They are cue or clusters of related assessment data that are signs, symptoms, or indications of an actual or health-promotion diagnosis.

Question 7

Data clustering

Answer 7

Organizing patient assessment data into groupings with similar underlying causes.
Looks for cues among the data that support the diagnosis of a problem

Question 8

Accurate data collection

Answer 8

Nurses responsibility to collect accurate, extensive assessment data and analyze them on the basis of accurate scientific knowledge.
Nurses responsibility to stay current in nursing research to provide the best care possible

Question 9

Formulating related factors

Answer 9

Underlying etiology or cause of patients concern or situation, should be used as a related factor when writing a nursing diagnosis.

Question 10

Explain basic nursing diagnosis methodology

Answer 10

Second step in nursing process.
When deciding on accurate nursing diagnoses for a patient, the nurse makes clinical judgements about a patients experiences and responses to identified problems or life events expressed during the data collection process

Question 11

Describe the historical development of NANDA-I and the nursing taxonomy

Answer 11

In 1973 the first conference met.
Continue to meet every 2 years.
Continues with the original goals of generating, naming and implementing nursing diagnostic categories, as well as revising taxonomy, promotions research and encouraging nurses to use taxonomy.

Question 12

Three parts of an actual nursing diagnosis

Answer 12

Diagnosis label, related factors, defining characteristics

Question 13

Two parts of risk nursing diagnosis

Answer 13

Diagnosis label and risk factors

Question 14

Two parts of health-promotion diagnosis

Answer 14

Diagnosis label and defining characteristics

Question 15

Implement the steps for accurately identifying nursing diagnoses.

Answer 15

Achieved through careful analysis and clustering of patient data, followed by verification of the specific nursing diagnoses for use with each individual patient

Question 16

Discuss how to avoid common problems associated with the diagnostic process

Answer 16

Writing concise, properly developed nursing diagnoses, the nurse must avoid clustering unrelated data, accepting erroneous data, using medical diagnoses are related factors in the nursing diagnostic statement, missing the true underlying etiology of a problem, and identifying multiple nursing diagnoses labels in one nursing diagnostic statement.

Question 17

Articulate the contribution of nursing diagnoses to the individualized care of patients

Answer 17

As the second step of the nursing process, the nursing diagnosis provides a framework on which nurses provide care to patients in an organized and effective manner.
An accurate nursing diagnosis promotes positive patient outcomes, quality patient care and patient satisfaction.

Question 18

What is the most important reason for nurses to use a standardized taxonomy such as NANDA-I?

Answer 18

Patient safety

Question 19

Which of the following nursing diagnoses is appropriately written?

Answer 19

READINESS FOR ENHANCED RELATIONSHIP as evidenced by mutual respect verbalized by spouses and expressed desire for improved communication.
NONCOMPLIANCE related to an inability to access care as evidenced by failure to keep appointments, home bound status.
RISK FOR BLEEDING with the revise factor of prolonged clotting time.

Question 20

Which phrase best represents a related factor in an actual nursing diagnosis?

Answer 20

Ineffective adaptation to recent loss

Question 21

Which action does the nurse need to take before determining the types of nursing diagnoses that are applicable to a patient?

Answer 21

Thoroughly review the patients medical history.
Analyze the nursing assessment data to determine whether info is complete.
Consider potential complications to which the patient is susceptible

Question 22

What is the primary difference between a risk nursing diagnosis and an actual nursing diagnosis?

Answer 22

Defining characteristics are not part of a risk diagnosis

Question 23

What is the most important action for a nurse to take in order to have a new nursing diagnosis considered for inclusion in the NANDA-I taxonomy?

Answer 23

Provide evidence based research to support nursing care

Question 24

What is the most significant problem that may result from improperly written nursing diagnostic statements?

Answer 24

Lack of direction for formulating patient plans of care

Question 25

Which statement best describes the relationship of medical diagnoses and nursing diagnoses?

Answer 25

Medical diagnoses may be interrelated to nursing diagnoses

Question 26

A patient has just experienced a cardiac arrest on the unit. The nurse has implemented the acute care plan for management of code situations. What is the next step the nurse should take?

Answer 26

Perform the steps of the nursing process related to the patient’s current condition

Question 27

What signs and symptoms would the nurse appropriately cluster for a patient with extreme anxiety?

Answer 27

Elevated pulse rate auscultated at 140 BPM.
Continuous foot tapping throughout intake interview.
Patient states, “ I feel nervous all the time, especially when I am alone.”