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[3] NUR114 | FUNDAMENTALS > Diagnosis > Flashcards

Diagnosis Flashcards

1
Q
  • The second phase of the nursing process
  • Pivotal step in the nursing process
A

Diagnosing

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2
Q

In the diagnosing phase, the nurse uses __________ to interpret assessment data and identify client strengths and problems.

A

critical thinking skills

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3
Q

Activities preceeding the diagnosing phase are directed toward formulating the __________

A

nursing diagnoses

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4
Q

Refers to the reasoning process

A

Diagnosing

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5
Q

Statement or conclusion regarding the nature of a phenomenon

A

Diagnosis

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6
Q

Contains a diagnostic phrase or diagnostic label followed by an etiology phase

A

Nursing Diagnosis

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7
Q

Statement of the client’s problem

A

Diagnostic Phrase

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8
Q

Causal relationship between the client’s problem or risk factors

A

Etiology

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9
Q
  • Responsible for making nursing diagnoses
  • Accountable for analyzing data to determine diagnoses or issues
A

Professional Nurses (registered nurses)

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10
Q

Are not educated to diagnose or treat diseases such as diabetes mellitus

A

Generalist Nurses

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11
Q

Nursing diagnoses describe a continuum of health states:
- (1) __________ from health
- (2) presence of __________
- (3) areas of enhanced __________

A

(1) deviations
(2) risk factors
(3) personal growth

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12
Q
  • Is also known as a problem-based diagnosis
  • Is a client problem that is present at the time of the nursing assessment
  • Based on the presence of associated signs and symptoms
A

Actual Nursing Diagnosis

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13
Q
  • Client’s preparedness to implement behaviors
  • Willingness to learn about health maintenance
  • Willingness to change health practices
A

Health Promotion Diagnosis

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14
Q
  • Clinical judgement that a problem does not exist
  • Presence of risk factors indicates that a problem is likely to develop unless nurses intervene
A

Risk Nursing Diagnosis

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15
Q
  • Clinical nursing judgement when a client has several similar nursing diagnoses
A

Syndrome Diagnosis

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16
Q
  • Describes the client’s health problem and client’s health status
  • Directs the formation of client goals and described outcomes
A

Problem Statement / Diagnostic Label

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17
Q
  • Added to the nursing diagnosis to provide additional meaning to the diagnostic statement
A

Qualifiers

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18
Q
  • Identifies one or more probable causes of the health problem, gives direction to nursing therapies, and enables individualization of client’s care
  • Clarifies the meaning of the diagnosis
A

Etiology

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19
Q
  • Cluster of signs and symptoms that indicate the presence of a particular diagnostic label
  • Client’s signs and symptoms
A

Defining Characteristics

20
Q
  • Provides a way to describe the client’s area of concern
  • Clinical judgement that concerns a human response to a health condition that nurses, by virtue of thier education, experience, and expertise, are licensed to treat
A

Nursing Diagnosis

21
Q
  • Made by a physician
  • Refers to a condition that only a physician can treat
  • Refer to the disease processes: specific pathophysiologic responses that are fairly uniform from one client to another
A

Medical Diagnosis

22
Q

Nursing diagnoses relate primarily to the nurse’s ___________, which are the areas of healthcare that are unique to nursing and separate and distinct from medical management

A

independent functions

23
Q

With regard to medical diagnoses, nurses are obligated to carry out physician-prescribed therapies and treatements, that is, __________

A

dependent functions

24
Q
  • A type of potential problem that nurses manage using both independent and physician-prescibed interventions
A

Collaborative Problem

25
Q
  • Is the separation into components of the diagnostic process
  • Breaking down of the whole into its parts
A

Analysis

26
Q
  • Putting together of parts intot the whole (inductive reasoning)
A

Synthesis

27
Q

The diagnostic process is used __________ by most nurses

A

continuously

28
Q

The diagnostic process has three steps:
- Analyzing (1) __________
- Identifying (2) __________
- Formulating (3) __________

A

(1) data
(2) health problems, risks, and strengths
(3) diagnostic statements

29
Q

In the diagnostic process, analyzing involves the following steps:
1. Compare the data against (1) __________
2. Cluster the (2) __________
3. Identify (3) __________

A

(1) standards
(2) cues
(3) gaps and inconsistencies

30
Q

Is generally a accepted measure, rule, model, or pattern

A

Standard / Norm

31
Q

A process of determining the relatedness of facts and determining whether any patterns are present, whether the data represent isolated incidents, and whether the data are significant

A

Clustering Cues

32
Q
  • Are conflicting data
  • Measurement error, expectations, and inconsistent or unreliable reports
A

Inconsistencies

33
Q

The basic two-part diagnostic statements includes the following:
1. __________: the statement of the client’s response
2. __________: factors contributing to or probable causes of the responses

A

Problem (P)
Etiology (E)

34
Q

The two parts of the diagnostic statement are joined by the words (1) _______ rather than (2) _______

A

(1) related to
(2) due to

35
Q

For a nursing diagnosis that contains the word “__________”, the nurse must add words to indicate the problem more specifically.

A

“specify”

36
Q

TRUE OR FALSE
Write diagnostic statements as they would be stated in normal conversation
e.g., Potential for infection

A

TRUE

37
Q

The basic three-part nursing diagnosis statement

A

PES Format

38
Q

The PES Format for diagnostic statements include the following:
1. __________: statement of the client’s response
2. __________: factors contributing to or probable causes of the response
3. __________: defining characteristics manifested by the client

A

(1) Problem (P)
(2) Etiology (E)
(3) Signs & Symptoms (S)

39
Q

The PES format cannot be used for _________ because the client does not have signs and symptoms of the diagnosis

A

risk diagnoses

40
Q

To minimize long problem statements, the nurse lists the __________ on the care plan below the nursing diagnosis, grouping the subjective (S) and objective (O) data.

A

signs and symptoms

41
Q

Some diagnostic statements, such as health promotion diagnoses and syndrome nursing diagnoses, consist of a __________ only.

A

nursing diagnosis label (one-part statements)

42
Q

Writing __________ when the defining characteristics are present but the nurse does not know the cause or contributing factors

A

unknown etiology
(Non-adhereance to medical regimen related to UNKNOWN ETIOLOGY)

43
Q

Using the phrase __________ when there are too many etiologic factors or when they are too complex to state in a brief phrase.

A

complex factors
(Chronic pain related to COMPLEX FACTORS)

44
Q

When the nurse believes that more data are needed about the client’s problem or etiology, the word ________ is inserted.

A

possible
(Alteration in throught processes POSSIBLY related to unfamiliar surroundings)

45
Q

Using __________ to divide the etiology into two parts, following a pathopysiologic or disease process or medical diagnoses

A

secondary to
(Impaired skin integrity related to decreased peripheral circulation SECONDARY to diabetes)

46
Q

Adding a __________ to the general response or nursing diagnosis label to make it more precise

A

second part
(Altered skin integrity [LEFT LATERAL ANKLE] related to decreased peripheral circulation)

[3] NUR114 | FUNDAMENTALS (15 decks)

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