Fundamentals: Chapter 17

Question 1

What is a medical diagnosis?

Answer 1

the identification of a disease condition based on a specific evaluation of physical signs, symptoms, the patient’s medical history and the results of diagnostic tests and procedures.

Question 2

What is a nursing diagnosis?

Answer 2

a CLINICAL judgement about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat.

Question 3

Who is licensed to make a medical diagnosis?

Answer 3

a physician

Question 4

What is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient’s status?

Answer 4

collaborative problem

Question 5

Why is selecting the correct nursing diagnosis essential?

Answer 5

accurate diagnosis of patient problems ensures that the nurse selects more effective and efficient nursing interventions

Question 6

What is a set of signs or symptoms gathered during assessment that you group together in a logical way?

Answer 6

data cluster

Question 7

What are the clinical criteria that are observable and verifiable?

Answer 7

defining characteristics

Question 8

What is an objective or subjective sign, symptom, or risk factor that, when analyzed with other criteria, leads to a diagnostic conclusion?

Answer 8

clinical criterion

Question 9

What is a condition, historical factor, or etiology that gives a context for the defining characteristics and shows a type of relationship with the nursing diagnosis?

Answer 9

related factor

Question 10

What are the three types of nursing diagnosis?

Answer 10

actual nursing diagnosis

risk diagnosis

health promotion diagnosis

Question 11

Describe an actual nursing diagnosis

Answer 11

human responses to health conditions or life processes that EXIST in an individual, family, or community

Question 12

Describe a risk nursing diagnosis

Answer 12

human responses to health conditions or life processes that MAY develop in a VULNERABLE individual, family, or community.

Question 13

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

Answer 13

risk diagnosis do not have related factors or defining characteristics because they have not occurred

Question 14

What are categories of risk factors?

Answer 14

Environmental

Physiological

Psychological

Genetic

Chemical

Question 15

Describe a health promotion nursing diagnosis

Answer 15

a clinical judgment of a person’s, family’s, or community’s motivation, desire and readiness to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors

Question 16

What are the two components of a nursing diagnosis?

Answer 16

NANDA-I diagnostic label

Related Factor (etiology)

Question 17

What is a diagnostic label?

Answer 17

the name of the nursing diagnosis as approved by NANDA International

Question 18

Why is a diagnostic label used?

Answer 18

it describes the essence of a patient’s response to health conditions in as few words as possible

Question 19

How does a nurse identify related factors?

Answer 19

use the patient’s assessment data

Question 20

What are the four categories of related factors for NANDA-I diagnosis?

Answer 20

Pathophysiological (biological or psychological)

Treatment-related

Situational (environmental or personal)

Maturational

Question 21

How do nursing interventions effect the medical diagnosis?

Answer 21

They do not change a medical diagnosis. Interventions must be directed at behaviors or conditions that the nurse is able to treat or manage

Question 22

What does PES stand for?

Answer 22

Problem (label)

Etiology (related factor)

Symptoms (defining characteristics)

Question 23

What is the cause of not being able to validate data?

Answer 23

an inaccurate match between clinical cues and nursing diagnosis

Question 24

What causes errors in data clustering?

Answer 24

data is clustered prematurely, incorrectly, or not at all

Question 25

List 12 ways to reduce errors in diagnostic statements:

Answer 25

1. Identify the patient’s response, not the medical diagnosis
2. Identify a NANDA-I diagnostic statement, not the symptom
3. Identify a treatable etiology, not a clinical situation sign or chronic problem that is not treatable through nursing intervention
4. Identify the problem caused by the tx or dx study, not the tx or study itself
5. Identify the pt response to the equipment, not the equipment itself
6. Identify the patient’s problems, not your problems with nursing care
7. Identify the patient problem, not the nursing intervention
8. Identify the patient problem, not the goal of care
9. Make professional judgments, not prejudicial judgments
10. Avoid legally inadvisable statements
11. Identify the problem and etiology to avoid circular statement
12. Identify only one patient problem in the dx statement

KEYS: PATIENT-CENTERED DIAGNOSIS; COMPLETE DX BEFORE PLANNING/IMPLEMENTATION

Question 26

What makes a nursing diagnosis unique from a medical diagnosis?

Answer 26

the patient can be involved in the diagnostic process