Chapter 17 Nursing Diagnosis Flashcards
- Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.)
A. Anxiety related to fear of dying
B. Fatigue related to chronic emphysema
C. Need for mouth care related to inflamed mucosa
D. Risk for infection
A and D
Rationale:
The diagnosis “Anxiety related to fear of dying” is stated correctly, with the related factor being the patient’s response to a health problem. Risk for infection is a risk factor for an at-risk diagnosis. In all cases the related factor or risk factor is a condition for which the nurse can implement preventive measures. Fatigue related to chronic emphysema is incorrect since chronic emphysema is a medical diagnosis. Need for mouth care related to inflamed mucosa is not a NANDA-I–approved nursing diagnosis.
2. A nurse reviews data gathered regarding a patient's pain symptoms. The nurse compares the defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as the correct diagnosis. This is an example of the nurse avoiding an error in: A. Data collection. B. Data clustering. C. Data interpretation. D. Making a diagnostic statement.
C
Rationale:
In the review of data, the nurse compares defining characteristics for the two nursing diagnoses and selects one based on the interpretation of data. Making a diagnostic statement is incorrect because the nurse has not included a related factor.
3. The nursing diagnosis readiness for enhanced communication is an example of a(n): A. Risk nursing diagnosis. B. Actual nursing diagnosis. C. Health promotion nursing diagnosis D. Wellness nursing diagnosis.
C
Rationale:
A patient’s readiness for enhanced communication is an example of a health-promotion diagnosis because it implies the patient’s motivation and desire to strengthen his health.
- In the following examples, which nurses are making nursing diagnostic errors? (Select all that apply.)
A. The nurse who listens to lung sounds after a patient reports “difficulty breathing”
B. The nurse who considers conflicting cues in deciding which diagnostic label to choose
C. The nurse assessing the edema in a patient’s lower leg who is unsure how to assess the severity of edema
D. The nurse who identifies a diagnosis on the basis of a single defining characteristic
C and D
Rationale:
When the nurse assesses edema without knowing how to assess the severity, the nurse 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. In identifying a diagnosis on the basis of a single defining characteristic, the nurse prematurely closes clustering, which can lead to an inaccurate diagnosis. By listening to lung sounds after the patient reports “difficulty breathing” the nurse validates findings to make an accurate diagnosis. The nurse interprets cue clusters to make an accurate diagnosis when considering conflicting cues to make a diagnosis.
- A nurse is reviewing a patient’s list of nursing diagnoses in the medical record. The most recent nursing diagnosis is diarrhea related to intestinal colitis. This is an incorrectly stated diagnostic statement, best described as:
A. Identifying the clinical sign instead of an etiology.
B. Identifying a diagnosis based on prejudicial judgment.
C. Identifying the diagnostic study rather than a problem caused by the diagnostic study.
D. Identifying the medical diagnosis instead of the patient’s response to the diagnosis.
D
Rationale:
In this example intestinal colitis is a medical diagnosis and thus an incorrect diagnostic statement.
- Review the following list of nursing diagnoses and identify those stated incorrectly. (Select all that apply.)
A. Acute pain related to lumbar disk repair
B. Sleep deprivation related to difficulty falling asleep
C. Constipation related to inadequate intake of liquids
D. Potential nausea related to nasogastric tube insertion
A,B,and D
Rationale:
Acute pain related to lumbar disk repair uses a medical diagnosis as a related factor. Sleep deprivation related to difficulty falling asleep uses a clinical sign rather than a treatable etiology such as “excess noise in environment.” Potential nausea related to nasogastric tube insertion uses a diagnostic study as the etiology. None of the etiologies can be managed or treated by nursing intervention.
- 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 of the following data form a cluster, showing a relevant pattern? (Select all that apply.)
A. Vital sign results B. Abdominal distention C. Age of patient D. Change in bowel elimination pattern E. Abdominal pain F. No past history of hospitalization
B, C, and E
Rationale:
The presence of abdominal pain, distention, and a change in bowel elimination pattern forms a cluster, suggesting an elimination problem.
- The nurse in a geriatric clinic collects the following information from an 82-year-old patient and her daughter, the family caregiver. The daughter explains that the patient is “always getting lost.” The patient sits in the chair but gets up frequently and paces back and forth in the examination room. The daughter says, “I just don’t know what to do because I worry she will fall or hurt herself.” The daughter states that, when she took her mother to the store, they became separated, and the mother couldn’t find the front entrance. The daughter works part time and has no one to help watch her mother. Which of the data form a cluster, showing a relevant pattern? (Select all that apply.)
A. Daughter's concern of mother's risk for injury B. Pacing C. Patient getting lost easily D. Daughter working part time E. Getting up frequently
B, C and E
Rationale:
Pacing, getting lost, and hyperactivity are a cluster of defining characteristics that point to the diagnostic label of wandering.
- Which of the following are examples of collaborative problems? (Select all that apply.)
A. Nausea
B. Hemorrhage
C. Wound inflection
D. Fear
B and C
Rationale:
Hemorrhage and wound infection are collaborative problems, actual or potential physiological complications. Nurses typically monitor for these to detect changes in a patient’s status. Nausea and fear are both NANDA-I approved nursing diagnoses.
- Two nurses are having a discussion at the nurses’ station. One nurse is a new graduate who added, “Patient needs improved bowel function related to constipation” to a patient’s care plan. The nurse’s colleague, the charge nurse says, “I think your diagnosis is possibly worded incorrectly. Let’s go over it together.” A correctly worded diagnostic statement is:
A. Need for improved bowel function related to change in diet.
B. Patient needs improved bowel function related to alteration in elimination.
C. Constipation related to inadequate fluid intake.
D. Constipation related to hard infrequent stools.
C
Rationale:
Constipation related to inadequate fluid intake is an accurate NANDA-I approved nursing diagnosis with an appropriate etiology. Need for improved bowel function related to change in diet is a goal with an etiologic factor. Patient needs improved bowel function related to alteration in elimination is a goal with a diagnostic statement. Constipation related to hard infrequent stools is a nursing diagnostic label with a clinical sign.
- The following nursing diagnoses all apply to one patient. As the nurse adds these diagnoses to the care plan, which diagnoses will not include defining characteristics?
A. Risk for aspiration
B. Acute confusion
C. Readiness for enhanced coping
D. Sedentary lifestyle
A
Rationale:
A risk diagnosis does not have defining characteristics, but instead risk factors. Risk factors are the environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem.
