Nursing Diagnosis/Analyze Cues

Question 1

Why is a nursing diagnosis/patient problem made?

Answer 1

When a nurse identifies a health-related problem or the potential to develop a problem based on patient data

Question 2

Which step of the nursing process is making a diagnosis?

Answer 2

The second step of the nursing process
And the 2nd and 3rd step of the CJMM process

Question 3

What is a medical diagnosis?

Answer 3

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

Question 4

What is a nursing diagnosis / nursing problem identification?

Answer 4

A clinical judgement made by a nurse to describe a patient’s response or vulnerability to health conditions or life events that a nurse is licensed and competent to treat

Question 5

Which categories are we looking at when identifying the nursing problem / nursing diagnosis?

Answer 5

Pathophysiological
Treatment-related
Personal
Environmental
Maturational (**Erickson and Maslow)

Question 6

Define collaborative problems

Answer 6

A problem that requires both medicine and nursing interventions to treat

Question 7

What would make a physiological problem not be a collaborative problem?

Answer 7

If a nurse can prevent the onset of a complication or provide the primary treatment for it, then it is a nursing problem

Question 8

What is a problem-focused nursing problem statement?

Answer 8

Identify an undesirable human response to existing problems or concerns of a patient

Question 9

What is a risk problem nursing problem statement?

Answer 9

Diagnoses that apply when there is an increased potential or vulnerability for a patient to develop a problem or complication

Question 10

What is a health promotion nursing problem statement?

Answer 10

Identify the desire or motivation to improve health status through a positive behavioral change

Question 11

Order of critical thinking and the nursing process/CJMM

Answer 11

Assess patient’s health status
Validate data with other sources
Interpret and analyze meaning of data
Data clustering/patterns
Look for assessment findings and related factors
Identify patient needs
Formulate nursing diagnosis and collaborative problems

Question 12

What is a data cluster?

Answer 12

A set of assessment findings/defining characteristics

Question 13

How should you find a data cluster?

Answer 13

By comparing a patient’s data with info that is consistent with normal, healthy patterns

Question 14

What does data interpretation involve?

Answer 14

• Placing a label on your data pattern or cluster to clearly identify a patient’s health problem
• Comparing the data in a cluster with the data standard
• Recognizing data in a logical cluster or revealing the nursing problems(s), how a patient is responding to a health condition or life process

Question 15

Components of a nursing diagnosis statement:

Answer 15

Diagnostic label
Related factors (etiology)
Major assessment findings (as evidenced by - cues)

Question 16

How should you keep in mind cultural relevance when using the nursing process?

Answer 16

Must consider your patients’ cultural diversity
Including ethnicity, values, beliefs, language, and health practices

Question 17

Type of nursing problem that is always applied to vulnerable populations?

Answer 17

Risk problem

Question 18

How do diagnoses/nursing problems affect the planning process?

Answer 18

• They direct it and help select the nursing interventions to achieve desired outcomes for patients
• Demonstrate your accountability for patient care

Question 19

How should you prioritize nursing problems?

Answer 19

*Using Maslow’s model, starting at the base

Question 20

Define priority setting

Answer 20

The ordering of nursing diagnoses or patient problems to establish a preferential order for nursing interventions

Question 21

How are priorities of patient care categorized?

Answer 21

Priorities are either high, intermediate or low importance

Question 22

How does a nurse determine which priorities are high, intermediate, or low importance?

Answer 22

Using Maslow’s hierarchy of needs

Question 23

Which types of problems fall into each category of patient care?

Answer 23

• High priorities are immediate needs (ABC’s)
• Intermediate priorities are nonemergent and not life threatening
• Low importance priorities are not always directly related to a specific illness/prognosis, but affect a patient’s long term wellbeing

Question 24

What is the difference between a goal and an expected outcome?

Answer 24

A goal is broad and is an ultimate outcome
Expected outcomes are the measurable changes the patient achieves to reach a goal

Question 25

What is the SMART acronym used for?

Answer 25

To correctly write out an outcome for a goal of care

Question 26

What are the 5 levels of Maslow’s hierarchy of needs?

Answer 26

Physiological
Safety
Love/belonging
Esteem
Self-actualization

Question 27

Explain what each aspect of the SMART acronym stands for

Answer 27

Singular
Measurable
Attainable
Realistic
Timed

Question 28

*What is an independent nursing intervention?

Answer 28

*An intervention that a nurse initiates in response to a nursing problem, without supervision, direction, or orders

Question 29

Example of an independent nursing intervention

Answer 29

Turning a patient

Question 30

What is a dependent nursing intervention?

Answer 30

Health care provider-initiated interventions that require an order from a health care provider

Question 31

Example of a dependent nursing intervention

Answer 31

Giving a patient pain medication

Question 32

What is a collaborative/interdependent intervention?

Answer 32

Require combined knowledge, skill, and expertise of multiple healthcare providers